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
Comprehensive Alpaca Record & Evaluation (CARE) Compiled by Laura Coussens, Kissin' Coussens Alpacas (KCA), 2000 The CARE checklist is for recording pertinent information, including strengths andweaknesses, for the purpose of buying, selling and breeding alpacas. Theassistance of a qualified veterinarian is required to safely and accurately completethis evaluation. Related animals m
FIRST EDITION : 15,03,95 EDITION N° 18 PRODUCTS CHARACTERISTICS DIPHOTERINE HEXAFLUORINE 30952 SYNTHOPON DAH94-505 ABSOLUE ALGUE MOUSSE ARBRE SUR HUILE VEGETALE E_3104 ABSOLU MOUSSE D'ARBRE ABSOLU MOUSSE CHENE ACMOSAN 82-6001 ACMOSOL 130-11 ACNOS 30-1003-111 ACTICARBONEACIDE ACTICIDE 14 ACTICIDE SPX ACTICATEUR N°2 ALD CYCLAMEN ALDEHYDE C9