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STUDENT NAME: ____________________________
2013-2014 Medications Agreement
Each family is required to fill out this form
, even if your student is not taking any medications during trips (if this is the case, please read through the below information and see reverse). In the spirit of establishing a system that works for each family, we would like you to choose how you want medications handled. Below are some things to keep in mind.
Each trip group has an extensive first aid kit that the leaders carry. It includes generic supplies for injuries as
well as illness. Those include (but are not limited to): decongestants (for cold-like symptoms), ibuprofen (pain
reliever and anti-inflammatory), acetaminophen (pain reliever and fever reducer), antihistamine (allergies, al-
antacid (upset stomach), Pepto Bismol (diarrhea, nausea, upset stomach), throat lozenges
(sore throats, also contain sugar for hypoglycemic emergencies), hydrocortisone cream (allergic reactions,
bites and stings), Imodium (loperamide is the generic name - for more severe diarrhea), Epi-pen (epinephrine
injection for unexpected life-threatening anaphylactic allergic reactions), Arithromycin (antibiotic for severe diar-
rhea infections), and Monistat (vaginal yeast infections - resulting from uncleanliness or antibiotics). Our group
first aid kit is sufficient for the entire group for the entire trip.
Our staff is prepared to provide the above medications when the noted symptoms are reported by the student or observed by the staff, unless symptoms don’t improve and more advanced medical help is needed (eg: diar-rhea that won’t go away, etc.) Please keep in mind it is essential that trip leaders know if a student is using any of the above medications so that we can monitor whether the symptoms are getting better or worse, are being treated correctly and thoroughly, and so that we can make good decisions about the itinerary based on group health. That said, we want you to decide what medications your student brings in addition to any prescriptions they might hold, especially if they have a history of a certain illness (eg: motion sickness, traveler’s diarrhea, etc.).
If your student has a history or a chance of having an anaphylactic allergic reaction
, please make sure the
Medical Form clearly states that and send 2 personal doses of epinephrine with your student to carry at all
times. It is much harder in other countries to determine exact food sources for those who have food allergies.
Please list all prescription medications your student will be taking with them on trips
Reason for Use
STUDENT NAME: ____________________________
Please list all non-prescription medications your student will be taking with them on trips
Reason for Use
All medications need to be in their original containers. Prescription medications must have the pharmacy label indicating who the medication is for (the name on the prescription needs to match your student’s name) and the dosage. If you have medications packaged otherwise, airport security is likely to not let you enter/exit countries with that medication on international trips.
If any student has medication that has been known to be used recreationally or might pose a risk for the group, trip leaders must carry that medication. Those include but are not limited to: Ambien, Ritalin, Concerta, Klono-pin, several pain medications, etc. We trust that students will use medications responsibly and as prescribed/indicated; failure to do so will be considered a violation of the school’s drug and alcohol policy. If leaders find that students are not taking their medications appropriately the leaders may take responsibility for carrying and administering those medications. Students who bring medications other than what is listed on this form may jeopardize their participation on the trip.
Parents/Guardians: please check the situation below that best describes how you would like prescrip-
tion medications handled:
____ My student can completely handle the responsibility of carrying and administering his/her own prescription medications.
____ My student can carry his/her own medications and can administer them but needs daily reminders to take them.
____ My student needs his/her trip leader to carry and administer medications throughout the trip.
___ My student will NOT be bringing either prescription or non-prescription medications on trips.
Students often request Ibuprofen, Tylenol, Tums, etc. during the school day. Please check the situa-
tion below that best describes how you would like your student’s OTC medications requests handled:
____ Realms has my consent to provide a recommended dosage of any the following OTC medications as needed by my student:
____ Do not provide any OTC medications without verbal or written consent from a parent/guardian.
By signing below, I agree to what is selected above and give Realms Staff permission to administer
any of the medications listed in the first aid kit and treat injuries within the scope of their training if
symptoms warrant. **Please inform us of any changes to this form throughout the year, as we recog-
nize things do change!
___________________________ ! _________________________ !
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