Overnight Field Trip Medication Administration FormFor Learwood Middle School D.C. Trip

Prescriptive and Over the Counter MedicationsName (please print) Date of Birth

Student Address

Name of Parent or Guardian: Phone Number(s)

Name of Parent or Guardian: Phone Number(s)

List any known drug allergies/reactions

Please state any health issues we should be aware of:

__________________________________________________________________________________________________

Please list any prescribed or over the counter (OTC) medications your child is currently taking: If your child will be taking medications during the field trip that will be administered by the Avon Lake City School Staff, please complete the General Medication Form (MAR) on backside of this form. Please complete a separate MAR form for each prescriptive medication to be administered. The MAR must be completed and signed by both physician and parent/guardian for each prescriptive medication to be valid. Please refer to the medication administration policy.

Name of Medication: Dosage: Route: Times:

Name of Medication: Dosage: Route: Times:

Name of Medication: Dosage: Route: Times:

Name of Medication: Dosage: Route: Times:

To meet the unforeseen minor medical concerns (cramps, headache, motion sickness, upset stomach, etc.) the administrator in charge on the field trip may give over-the-counter medicines to the student to be administered according to package dosage and directions unless otherwise ordered by a physician with written permission from their parent to receive the medicines. If requested, can your child be given: (Check all that apply)_____Dramamine (for motion sickness)_____Ibuprofen or Advil or Motrin (for headache, fever, menstrual cramps)_____Tums (for indigestion, upset stomach) _____Tylenol (regular/extra strength) (for headache, fever, menstrual cramps)

If a student carries any medication without signed permission notification or shares medication with another student, they will be subject to disciplinary actions under the Drug and Alcohol Policy of Avon Lake City Schools.

The chaperones on this trip have permission to take my child to a hospital or medical facility for emergency medical or dental treatment. Please include a copy of your insurance card and attach to this form.Insurance Co.________________________________________Contract/Policy#_________________________________

I hereby agree to hold the Board of Education, the school principal, teachers, staff and any other chaperones harmless for any accident that may occur during the trip.Signed____________________________________________________________Date____________________________

(Parent/Guardian)

Procedures for Field Trips and Other off Campus ActivitiesFor Learwood Middle School Students Grades 7 and 8

MEDICATION PROCEDURE

MEDICATION PROCEDURE FOR OVERNIGHT FIELD TRIPS

Certain school activities involve travel away from the school property for overnight or longer periods. To accommodate the potential need for administration of medication at these activities, either over-the-counter or prescription, the following procedure will be followed.

1. When it is known that a student will require medication during the activity, the parent/guardian will need to do the following:

a. Must have the General Medication Administration Record (MAR) completed. Prescription medications will require written permission from the doctor and the parent/guardian. Over-the-counter medicines require a parent signature only and will be administered according to package dosage/directions unless otherwise ordered by a physician.

b. Prescriptive medications must be received in the container in which it was dispensed by the prescribing physician

or others licensed to prescribe medication. Prescriptive medications must be properly labeled with the student’s name, prescriber’s name, date of prescription, name of medication, dosage, strength, time interval, route of administration, and date of expiration when appropriate. PLEASE PACK ONLY THE NEEDED AMOUNTS OF MEDICATIONS FOR THE TRIP. NO MEDS WILL BE ACCEPTED IN BAGGIES OR OTHER CONTAINERS

c. Non-prescribed (over-the-counter medications) Ibuprofen, Tylenol, and Tums will be available from the chaperones on each bus as needed. For students taking Dramamine, it must be received in its original container with student’s name affixed to it and must be administered according to package dosage/directions unless otherwise ordered by a physician.

d. Chaperones will hold and dispense all medications to students, unless otherwise indicated in physicians order. For students requiring insulin, epi-pens, and/or inhalers, we are requesting a backup supply; one for the student and one for the chaperone.

e. The parent must submit the Medication Consent Form to the building nurse no later than two weeks prior to the trip to allow the building nurse to review the orders.

f. If under some unusual circumstances, the parent is unable to supply the permission form in the appropriate time frame, permission to carry may be given after review by the nurse and the principal.

g. All medications, both prescriptive and over-the-counter, are to be brought to school by the parent or guardian the night of luggage checks along with a copy of completed and signed medication forms. PLEASE PLACE ALL MEDICATION BOTTLES IN A LARGE ZIPLOCK CLEARLY LABEL BAG WITH YOUR CHILD’S COMPLETE NAME.

2. If the student is allowed to carry their medicine and shares the medication with another, the student will lose the privilege of carrying the medicine and will be subject to disciplinary action under the Drug and Alcohol Policy of Avon Lake City Schools. The student will give the remaining medication to the responsible staff member who will administer it according to the order on file.

3. If the student carries medicine without meeting the above criteria, the medication will be taken and the student will be subject to disciplinary action under the Drug and Alcohol Policy of Avon Lake City Schools.

4. To meet the unforeseen minor medical concerns (headache, cramps, motion sickness, upset stomach, etc.) the administrator in charge on the field trip may give over-the-counter medicines to the student with written permission from their parent to receive the medicines. These medicines will be: Dramamine, Ibuprofen, Tylenol, and Tums. This Discretionary Medication Permission form must be signed by the parent and returned to the school nurse no later than two weeks before the trip. This will allow time for the nurse to review and collate the information to give to the administrator.

5. If a student has an identified health need on his/her IEP or 504 Plan, and the parent of the eligible student does not accompany the student, efforts will be made to accommodate the medical needs. The building nurse should be informed of the need at least two weeks prior to the trip.

4/24/13