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Please complete both sides of this document.
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Parent/Guardian must bring any medications to school, prescription and Over the Counter.
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Students may not transport medication at any time.
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Medications must be in the original container and not expired.
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Medications currently stored at school will not be taken on this trip.
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Provide only the exact amount of medications your student will need for this trip.
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Inhalers/Epipens/Insulin/Diastat may be carried by the student with written physician approval on a school provided Action Plan.
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For inhalers, insulin, or Epipens, please fill out this side only. Copies of current 2015-16 school year action plans will be sent with the student’s chaperone.
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Prescription medications must have the student’s name and original prescription label on the bottle/box.
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Medications will be returned to students as they disembark at school on May 20 th .
Parent/Guardian to complete this section:
Please fill out a separate form for each medication sent in. Extra forms can be picked up in the clinic.
Student’s Name_______________________________________________________________
Medication to be given_________________________________________________________
Dosage and time to be given_____________________________________________________
Allergies_____________________________________________________________________
***Please note morning medications will not be given on May 18th and evening/bedtime medications will not be given on May 20th. Please give those medications at home the morning the students leave and the evening when they return.***
Below to be filled out by the student’s chaperone/teacher/school nurse. Chaperone, in blank, write time
given and initial.
Breakfast Lunch Dinner Bedtime
May 18 th ___XXX___ ________ ________ _________
May 19 th _________ ________ _________ __________
May 20 th _________ ________ ___XXX___ ____XXX___