The Medical Form on the Following Pages Must Be Completed for All Students

WILLIAMSBURG TRIP – MEDICATION POLICY

THE MEDICAL FORM ON THE FOLLOWING PAGES MUST BE COMPLETED FOR ALL STUDENTS

It is important for all parents and students to understand T/E’s policy regarding medication on overnight trips. No student may have any medications in their possession, both prescription and over the counter (i.e. Tylenol). The only exception is emergency medications meeting the requirements below.

Please note:

 In accordance with T/E’s medication policy, the nurse may only administer medication ordered by a physician. All medications you will be sending on this trip, both over the counter and prescription, should be listed on the next page and the form signed by a physician.

 Epi-pens, inhalers and diabetic supplies are considered emergency medication and may be carried by the student if a physician request form is on file in the nurse’s office.

 All medications being sent on the trip should be dropped off by the parent during the week of May 23rd but no later than Tuesday, May 31 to the nurse’s office. Medicines, both prescription and over the counter, must be in their original container/bottle. It would be helpful if you put the medication bottles/containers in a Ziploc bag with your child’s name on the bag.

 If any medical/medication information changes between when you actually submitted the medical form and the trip, please notify the nurse’s office.

 Again, medication will not be accepted if it is brought in by the student, if it is not in the original container or if not accompanied by a doctor’s order.

If you have any questions or concerns, please do not hesitate to contact me at the nurse’s office (610-240-1305).

Thank you,

Noreen Richardson, RN CSN

WILLIAMSBURG TRIP 2016

As we approach our upcoming trip to Williamsburg in June, we need some information from you to make our trip run as smoothly as possible. Please complete EVERY QUESTION on this form. Return this form to Mrs. Crothamel or Mr. Peltier by Friday, May 6, 2016. In addition, PARENTS of those students who require medication should turn in the medicine(s) to the school nurse before Tuesday, May 31, 2016.

Student’s Name______Date of Birth______

Parent/Guardian Name(s)______Home Phone #______

Address______

Parent/Guardian Work Phone Number(s) Father______Mother______

Parent/Guardian Cell Phone Number (s) Father ______Mother______

Emergency contact (name and number), if unable to reach parent:

______

Specify any known allergies to drugs, insect bites, food, or substances: ______

History of past illness that may affect emergency treatment: ______

Health/Hospital Insurance: ______Policy Number: ______

Name of Family Physician: ______Phone Number: ______

Licensed Health Personnel may provide if needed: Advil YES ___ NO ___ Tylenol YES __ NO __ Benadryl YES __ NO ___

NO MEDICATION, WITH THE EXCEPTION OF EPI-PENS AND INHALERS, MAY BE CARRIED BY THE STUDENT. A doctor/parent order form to self -carry must be on file in the health room.

If emergency treatment is required, I authorize the Director in charge of this trip to act on my behalf to secure the most accessible medical services.

Parent or Guardian Signature ______Date ______

MEDICATION TO BE TAKEN ON THE TRIP: include ALL medication- prescription and over the counter.

MEDICINE DOSE WHEN TO GIVE

1.______

2.______

3.______

4.______

Prescription Medication must be in the original, labeled prescription container. Over the counter medication must be in original packaging. It is not necessary to send Advil, Tylenol or Benadryl.

PHYSICIAN SIGNATURE:______DATE:______

STAMP OR PRINT PHYSICIAN NAME AND ADDRESS IN BOX:

(CONTINUE ON BACK OF THIS FORM!) **PARENTS MUST turn in all medications listed to the school nurse during the week of May 23rd but no later than Tuesday, May 31, 2016. All medicines must be in the ORIGINAL container with the original label. No unlabeled medications can be accepted.

STUDENTS CANNOT transport medicine!!!!!!!!!!! PARENTS MUST PERSONALLY bring the medicine directly to the school nurse. REMINDER…ALL MEDICINE must be in the ORIGINAL CONTAINERS!

NO MEDICATION CAN BE ACCEPTED THE MORNING OF THE TRIP!!

If you have any questions or concerns regarding this form, please call the school nurse directly to resolve the problem.

Background Information

Please indicate the level of proficiency/experience your son/daughter has in swimming:

(Circle one)

A. Non-swimmer C. Intermediate

B. Beginner D. Advanced

DIETARY RESTRICTIONS If your child has DIETARY restrictions or limitations, please email Mrs. Cannon directly at [email protected].

Return forms to the designated Science teacher (Mrs. Crothamel or Mr. Peltier) by Friday, May 6, 2016. THIS FORM MUST BE RETURNED BEFORE YOUR CHILD CAN BE CLEARED FOR THE WILLIAMSBURG TRIP EVEN IF NO MEDICINE WILL BE NEEDED. All medicines should be turned in to the NURSE on or before Tuesday, May 31, 2016.