Dear parent/guardian:

Instructions to Parents
Overnight Field Trip

In order for your child to participate in an overnight field trip, the enclosed packet of information must be
completed and returned to the school nurse no later than April 18th 2011. Failure to submit the necessary
information by the return date might result in your child not being able to participate.
Complete and return the enclosed Field Trip Permission Slip. EMERGENCY MEDICAL INFORMATION FORM
Complete and return the enclosed Emergency Medical Information Form. The Emergency Medical Information Form will be maintained by the teacher/chaperone in charge throughout the trip. The information provided will assist the teacher in understanding all necessary and relative information about your child. Please be specific and accurate as this information will be shared with emergency care providers should your child require emergency treatment for any reason. If a section does not apply to your child, please place N/A in the space provided. Allergies: list ALL known allergies
Dietary Restrictions: list any dietary restrictions that the chaperones should be aware.
Current Medications: list ALL medications being supplied for use by the student during the field trip
Contact Numbers: provide at least three (3) names and phone numbers of emergency contacts who will be available during the field trip period of time. It is recommended that the emergency contact be individuals capable of granting permission to treat in case of sudden illness or injury and who are aware of the specifics of your child’s health history. Health History: provide all relative health history information concerning your child that should be ADMINISTRATION OF MEDICATIONS BY SCHOOL PERSONNEL
An Authorization for the Administration of Medicines by School Personne Form must be completed for any
medication being supplied for the student during this trip. This includes any student currently receiving a
regularly scheduled medication while at school.
A new authorization form DOES need to be completed
because the current authorization form on file at the school only covers the time period of school hours and
does not cover the after school hours that will be required for the purposes of this trip.
All medication must be in the original container properly labeled with your child’s name. Authorization
forms and medications must be delivered to the school nurse no later than one (1) week prior to the departure
Please place prescription or over the counter medication to be administered by staff in a ziplock bag clearly
labeled with your child’s name.
In order for your child to carry and self-administer a prescription medication, the enclosed Authorization for the Administration of Medicines by School Personnel Form must be completed for each medication to
include the section entitled Self Administration of Medication Authorization/Approval. Students
MAY NOT carry and self-administer controlled substances such as Adderall, Ritalin, Strattera, Ativan,
Clonopin, Prozac, and narcotic pain medications. All medications carried by your child MUST be in the
original container, labeled with your child’s name.
Please be sure the following sections of the form are complete. Incomplete forms will not be accepted!
Name of drug
Condition for which drug is being administered
Dose and strength of drug
Time of administration
Dates during which medication shall be administered.
Relevant side effects
Physician’s Name and phone number
Physician’s Signature under section for Prescriber’s Authorization AND Self Administration of
Medication Authorization/Approval sections. Parent/Guardian Signature under section for Parent/Guardian Authorization AND Self
Administration of Medication Authorization/Approval sections PERMISSION TO CARRY AND SELF ADMINISTER OVER-THE-COUNTER MEDICATIONS
In order for your child to carry and self-administer over-the-counter medications, the enclosed Over-The-Counter Medication Orders for School Sponsored Field Trip Form must be completed and signed by your physician, parent and student. Any additional over-the-counter medications not listed on the form, must have an individual Authorization for the Administration of Medications form completed and submitted as described in the section above. HEALTH INSURANCE
Please provide your health insurance information for use in case of emergencies in the space provided on the Permission form or attach a copy of your health insurance card. Additional Trip Health Insurance coverage might be offered or required by the sponsoring agency of the trip. Contact the sponsoring agency for more details. If you have ANY questions please contact the school nurse at 844-3038 as soon as possible for assistance. 10/20/10pa



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