Medication Permission Form for Liberty Science Center Trip – 2/18-19/16
Per Cherry Hill District Policy and NJ state law, parental and physician signatures are required in order for the
school nurse to administer medication. No exceptions can be made.
If your child must have medication on this trip, complete this form where applicable. Place the completed form
in the zip-lock bag with the medications and deliver to Mrs. Avner at Beck by January 15, 2016. *Medically
Necessary medications only will be administered by the nurse while on the trip. Please administer daily
evening dose of medications to your child before the trip and your child’s morning dose when he/she arrives
home in the morning following the trip. All Medications including over the counter medicines require a
doctor’s order with the exception of Acetaminophen (Tylenol) and Ibuprofen (Advil or Motrin) which
require written permission from a parent/guardian. Medicines must be in the original pharmacy bottle
with the label intact. Do not include extra doses. It is not necessary to send Acetaminophen or
Ibuprofen.
Student Name: ___________________________ Team #_________________________
List all drug/medicine allergies:________________________________________________
Daily Medication(s):
Medication: ______________________________________________________________
Dose: ________________________Administration Time: ________________________
Medication: _____________________________________________________________
Dose: ________________________Administration Time: _______________________
Medication: ____________________Dose: ___________________________________
Administrative Time: ________________________
____ I authorize self-administration of an asthma inhaler/Epi Pen for the above noted student. (If
applicable) If additional medication forms are needed, please call the nurse, Mrs. Avner, 856424-4505, ext. 3132.
____ I request that the above medication(s) be given to my child by the school nurse while on the
Liberty Science Center school trip.
_____________________________
Parent/Guardian’s Signature
____________
Date
I request that the school nurse administer the above medications while on the school trip to the Liberty Science
Center.
______________________________ ____________ _____________________
Physician Signature
Date
Stamp
For Acetaminophen (Tylenol) or Ibuprofen (Advil or Motrin) Only
The nurse has my permission to administer (choose only one)
List all medicine/ drug allergies_______________________________________________
______ Acetaminophen (Weight based dose)
______ Ibuprofen (Weight based dose)
_________________________________
Parent/Guardian’s Signature
________ Benadryl (Weight based dose)
Without a written doctor’s order;
Benadryl will be administered in
An “emergency only” situation
____________
Date