Microsoft word - medical forms 2012.doc

Class Trip Medical Forms
Attached are several medical authorization forms that need to be completed and turned in by Friday, May 11th. Signed medical authorizations are required before each student to board the bus. All students are required to have completed Emergency Medical Authorization form and the Past Medical History/ OTC Medication form. Also included is a Prescription Medication form for completion if your child requires daily or as needed prescription medications. Note that prescription medication is to be delivered by the parent/ guardian on the morning of May 14th, in the original labeled container in which the pharmacist dispensed it. The class trip is a wonderful opportunity for our students to grow in many ways. While physical development of adolescents occurs in an orderly, predictable sequence, the same cannot be said of psychosocial development. For some students, separating from family is easy while others may have reservations about this transition. Please feel free to call us or email us with any personal concerns or helpful hints you may have regarding your child. We want this trip to be a wonderful experience for everyone. Thank you, Michael Graham Laura Frey EMERGENCY MEDICAL AUTHORIZATION FORM
Student Name: _____________________ Telephone:___________ Address: _____________________________________________ ______________________________________________ Date of birth: ______________
In the unlikely event that a student should require medical care during our trip,
this form enables parents to authorize the provision of emergency treatment for
a serious injury or illness.
Please list below the names of the adults (including yourself as parent/guardian)
who you would prefer for us to call in case of an illness or emergency. Please
put these names in the order of who should be called first, second, etc.
NAME
RELATIONSHIP
HOME AND CELL#
1. ___________________________________________________________ 2. ___________________________________________________________ 3. ___________________________________________________________ 4. ___________________________________________________________ TO GRANT CONSENT: In the event reasonable attempts to contact me have been unsuccessful, I hereby give my consent for the administration of any treatment deemed necessary by licensed healthcare provider or dentist; and the transfer of the student to an accessible hospital. SIGNATURE OF PARENT/GUARDIAN _____________________________ Past Medical History:
Authorization to Administer OTC Medications
Student Name: _________________________
The following are facts concerning my child’s medical history, including
allergies, medications being taken and any physical impairments or chronic
conditions:
Below is a list of OTC medications that we will have on hand for the students.
Please initial each medication that your child may take if the need arises.
MEDICATION
*INITIAL TO INDICATE PERMISSION TO
ADMINISTER
Parent/Guardian Signature:_______________________ Date:______________ REQUEST FOR ADMINISTRATION OF PRESCRIBED MEDICATION
All prescription medication is to be delivered by the parent/guardian in the original labeled container in which the licensed pharmacist dispensed it. The container needs to have a pharmacist’s label with the following information: physician’s name and telephone; name of medication; prescribed dosage and frequency. STUDENT NAME ______________________________________ ALLERGIES ___________________________________________________ THE FOLLOWING MEDICATION NEEDS TO BE ADMINISTERED DURING THE CLASS TRIP.

NAME AND DOSE OF THE DRUG: __________________________________________
AMOUNT TO BE ADMINISTERED ___________________________
TIMES OR INTERVALS OF ADMINISTRATION _______________________
IF p.r.n. (as needed), GIVE SPECIFIC INDICATIONS: _____________

OTHER SPECIAL INSTRUCTIONS (EXAMPLE: IF ALLOWED TO CARRY INHALER)
DATE TO BEGIN: ________________ DATE TO END: ____________
I REQUEST THAT THE DRUG PRESCRIBED BE ADMINISTERED TO MY CHILD.
PARENT/GUARDIAN SIGNATURE ______________________________________
DATE_________________________

***If more than one prescription medication is to be given,
please copy and complete one form for each. Thank you.

Source: http://erdkinder.net/sites/default/files/documents/Medical%20Forms%202012.pdf