6153 Form IV Side 2

NEWINGTON PUBLIC SCHOOLS

Health Services

Medications on Extended Day or Overnight Field Trip Form

Dear Parent or Guardian,

If it is necessary for your child to take medication during the school sponsored trip, please send the medication to the school nurse by __________________________ (1 week prior to field trip date).  The medications should be those that are medically necessary.  The medication MUST BE IN ITS ORIGINAL CONTAINER with your child’s name and the dosage and frequency.  A doctor’s written order should accompany the medication. 

Child’s Name _________________________________________________________________

Medication #1 ____________________________Dosage: ____________  Time: ___________

Frequency:  __________________  Special Handling:________________________________

Medication #2 ____________________________Dosage: ____________  Time: ___________

Frequency:  __________________  Special Handling:  _______________________________

I give permission for my child’s teacher to administer the above medication if needed as I and my health care provider have indicated.  I provide ONLY enough medication for the duration of the field trip.

__________________________________________

Parent / Guardian Signature – Date

The following EMERGENCY medications (such as an inhaler or an EpiPen) are self administered, as per doctor’s written authorization (REQUIRED AND ATTACHED):

Medication:  ______________________________________

Frequency:  _______________________________________

Time of Administration:  ____________________________

Reason for Medication:  _____________________________

If your child needs to carry an EMERGENCY medication – inhalers and EpiPens are the only medications a student may be allowed to carry on his/her person – please contact the school nurse to complete an additional required form.

__________________________________________

Parent / Guardian Signature – Date