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Medication permission request form

Medication Permission Request Form
Must be returned by February 14, 2014
The State of Massachusetts requires that all students who need prescription and
non-prescription medication (to include inhalers) during school hours or during school
functions (Field Trips) on a daily or as needed basis must do the following:
1. Present a written consent signed by the physician. 2. Present a written consent signed by the parent or legal guardian. 3. Bring the medication in the original prescription bottle (the pharmacy will provide a second bottle for school if you ask), properly labeled by a registered pharmacist as prescribed by law. Physician’s Order and Consent Form for Medication
To Be Given On a School Function (Field Trip)

School: Luther Burbank Middle School, Lancaster, Ma.
Student’s Name: _________________________________________ Date of Birth: _______________
Diagnosis: _____________________________________________________________________________
Prescription Medication
Medication
Duration
Side Effect
Non Prescription Medication - to be used only if / and when needed as determined by Trip R.N’s
Medication
As Needed
Acetaminophen-Tylenol
Ibuprofen or Advil
Benadryl
Dramamine or Bonine
Decongestants
Cough Syrup
Other: (specify)

PHYSICIAN’S SIGNATURE: ____________________________________________________

DATE: ____________________

Revision 9/12/2013
“Capital Experience 2014” - Luther Burbank Middle School’s Eighth Grade D.C. Trip
MAY 27 – MAY 30, 2014
Student Participant Health Information
To be completed by Parent or Guardian
Name _______________________________________________ Date of Birth ___________________ Address______________________________________________ Home Phone _________________________ Person to contact in case of emergency: (Please list 2) ________________________________ Work Phone _____________ Home Phone ___________ Cell _______________ ________________________________ Work Phone _____________ Home Phone ___________ Cell _______________ Does the student have any of the following? _____________________________________________ _____________________________________________ _____________________________________________ _____________________________________________ _____________________________________________ _____________________________________________ _____________________________________________ _____________________________________________ Name and Number of Plan _____________________________________________ Name of Subscriber __________________________________________________ Group Name & Number _______________________________________________ Insurance phone # to contact if prior approval is required _____________________ Medical Release
I, ___________________________, Legal Guardian of __________________________ grant to school trip nurse/chaperone(s), the right to obtain emergency medical or dental treatment for my child _____________________________ during the period of the Eighth Grade Washington, D.C. Trip, including but not limited to May 27, 2014 through May 30, 2014. Payment for any and all medical treatment is the financial responsibility of the parent/guardian. I give permission for the Trip Nurse to administer the medication(s) as directed by the physician’s orders. I give permission for my son / daughter to self-administer medication the trip nurse determines that it is safe I give permission for the Trip Nurse to share with appropriate trip personnel information relative to the prescribed medication, e.g. adverse side effects, as she determines necessary for my son’s / daughter’s Date ______________ Parent/Guardian Signature: ______________________________________

Source: http://burbank.nrsd.net/assets/files/Ursuliak/DC%20Health%20and%20Medical%20Forms%202013-14.pdf