Field trip medication order-consent form201

Field Trip Medication Order/Consent Letter Dear Parents,
This letter will provide answers to some of your frequently asked questions regarding
prescription medication administration on day and overnight field trips.
Q:
What forms do I need to fill out so that my child can receive their prescription
medication while on a field trip?
A:
You will need to complete one Field Trip Medication Order/Consent Form for any prescription medications. This form has to be completed by a licensed prescriber and
signed and dated by parents/guardians.
Q:
What if I have already filled out a Medication Order Form for this prescription
medication during this school year?
A:
Please make a note of this on the back of this form, sign it and date the parental/guardian consent section and return it to the School Nurse. The original form will
then be copied from the Nurse’s records and attached to this Field Trip Medication
Order/Consent Form.
Q:
Who will administer my child’s prescription medication during a school day field
A Wayland Middle School Staff member, trained and delegated by the School Nurse, will administer your child’s prescription medication.
Q:
Who will administer my child’s prescription medication during an overnight field
A Wayland Public School Staff member, trained by the parent or guardian, will administer your child’s prescription medication.
Q:
Will my child be carrying their prescription medication while on the field trip?
No, the delegated staff member will carry and administer the medication. The only exception to this will be in the instance of an Albuterol Inhaler or an EpiPen. **Students are strongly encouraged and asked to carry these medications on their persons at all times while on field trips** Q: How will the medication be sent on a field trip?
A:
On a school day field trip, if the School Nurse has possession of the medication, she will pack it from the Nurse’s office, and give it to the delegated staff member to carry and administer to your child. For the overnight field trips, please send only enough medication for the field trip in the original pharmacy bottle, with the original pharmacy label. All medication being sent on a field trip must come in the original pharmacy bottle or container. WAYLAND PUBLIC SCHOOLS Homeroom Teacher: __________________ Field Trip Medication Order/Consent Form Student’s Name: _________________________________ Date of Birth: _________ Sex: _____ Grade____ Address: _____________________________________________________________ (street) (City/town) Pertinent Medical Condition(s): _________________________________________________ Allergies: ____________________________________________________________________ Name of Licensed Prescriber: ____________________________________ Title: ___________ Telephone Number: _________________________________ Fax Number: ________________ Administration of Prescription Medications (completed by a LICENSED PRESCRIBER)
1. Name of Medication: ____________________Dosage: _____________ Route: __________
Frequency: ____________ Specific Directions: __________________________________________
2. Name of Medication: ____________________Dosage: _____________ Route: __________
Frequency: ____________ Specific Directions: __________________________________________
3. Name of Medication: ____________________Dosage: _____________ Route: __________
Frequency: ____________ Specific Directions: __________________________________________
4. Consent for Self Administration of Inhalers Only: ___ Yes ___ No
5. Other Medications Taken by the Student: ___________________________________________
6. ____Yes
____No The student is allowed to take OTC drugs such as acetaminophen,
ibuprofen, Benadryl, Claritin, Dramamine, etc. in combination with their prescription medications listed above, and as deemed appropriate by parents and staff.
Physician’s comments:
Licensed Prescriber’s Signature
Parental Consent
I give permission for a Wayland Public School staff member to administer the above medication(s) to
my child while on an overnight school field trip.
_____________________________________________ __________________________
Parent or Legal Guardian’s Signature

Source: http://waylandms.sharpschool.net/UserFiles/Servers/Server_1036732/File/Nurse/MedOrder.pdf