HEALTH FORMS:

The health forms will be distributed once a deposit has been made. The Health
Information and Permission form must be completed for each student. PLEASE
ANSWER EVERY QUESTION. The medication forms must be completed if
student is to take any medication, prescription or over the counter.

MEDICATION: There will be no exceptions to the following:

Read the school nurses form about medications, print it, complete it, and
send the bottom half to Ms Riggin-Jay. Plan for an adult to bring any
medicines to her by May 15. Have your doctor complete the prescriber
form if prescribed medicine is needed. Make copies if needed.
Any medication must be in its original box or prescription bottle and
unexpired.
Over the counter (non-prescription) medications must be in purchase
container and in a baggie with students name, directions, and dosage taped
to cover in some format.
Prescription medications must be in original pharmacy container that
displays childs name, dosage, doctors name, medication name.
Medications will be distributed by staff on the trip as is indicated.
If you or your child wishes to have the medication taken privately, please
indicate. However, please ascertain your child knows an adult will witness
consumption of all distributed medications.
*Some students may need to include a medication for travel sickness.
Thank you for your attention to these details. If you have any questions or
medical concerns that you would like to discuss, please feel free to call
Mr. DAlleva at 781/393-2228.

AMS Program_ NYC TRIP

Attendance Date JUNE 5,6,7, 2015

Students Name____________________________________
Parents Name________________________Home Phone ( )_________________
Street Address________________________ Bus. Phone ( )___________________
City________________________________ State________ Zip _________________
Family Doctor________________________Phone (
)______________________
Family Dentist________________________Phone (
)______________________
Health Insurance Co. __________________Policy #__________________________
HEALTH INFORMATION: To make your childs stay as pleasant as possible, we would
appreciate information regarding his/her health and any medical problems he/she may have.
Please complete in full.
1. Any food, drug, or other allergies (insect bites, pollen)?
______Yes ______No Specify_______________________________
reaction____________________________________________________
2. Any existing medical condition (chronic or recurring illness?)___________________
3. Is there any factor that makes it advisable for your child to follow a limited program
of physical activity, i.e., heart condition, recent fracture, surgery, asthma or extreme
fears?
______ Yes
______ No
4. Any special dietary needs?__________ If yes, please call _____________________
to discuss special dietary needs.
5. In order to protect your child from possible embarrassment, we would like to know:
Does he/she wet the bed at night?

______ Yes

______ No

Does he/she walk in his/her sleep? ______ Yes

______ No
6. Date of last Tetanus Shot (Tdap)_________________________________
7. Has your child been exposed to any communicable disease within the past 21 days:
_______ Yes
______ No If yes, What?__________________________
8. Will your child need any medication or pills of any sort (including over the counter
medication(s)
______ Yes
______ No

MEDICAL CONSENT:

Please give your consent to medical care by signing in the

space(s) provided below.

I consent to and authorize emergency and non-emergency medical care to be

provided to my child in the event of a health problem, emergency or injury
occurring during my childs attendance. I give my consent and authorization to the
chaperones of his/her designee to use his/her judgment in seeking medical care for
my child. I understand that the attempt will be made to contact me in the event
that medical care is needed.
Signature of Parent/Guardian__________________________ Date__________
OPTIONAL: If you wish, for religious or other reasons, you may indicate
your refusal to consent to certain medical care (e.g., blood transfusions) as
follows:
Notwithstanding the above, I do not consent to the following diagnostic
tests or medical treatment for my child:
Specify______________________________
Signature of Parent/Guardian_______________________________________
PLEASE BE SURE THAT YOU HAVE READ TRHOUGH THE CONSENT
FORM COMPLETELY AND CAREFULLY, AND HAVE SIGNED YOUR
SIGNATURE IN THE APPROPRIATE SPACES.
THE HEALTH INFORMATION AND PERMISSION FORM IS
REQUIRED BY EVERY STUDENT WHO IS PARTICIPATING IN THIS
TRIP.
In case of an Emergency, please contact:

Name_________________________Relationship____________Phone________________

Name_________________________Relationship____________Phone________________

Andrews Middle School Overnight Field Trip

Medication/Health Form
Please write the name of your child, any medical conditions your child has that the Field Trip teachers should know
about, and any medications that you will be asking the teachers to give your child on the Field Trip. NO
STUDENT may bring medicine TO SCHOOL OR TO THE TRIP except inhalers and Epipens, and Insulin for
which the school nurse has current (2014 - 2015) prescriptions on file. On the Field Trip, Andrews teachers will
carry all medicines for Andrews students. Please sign and return this form even if all the blanks are none.
--If your child needs a prescription medication, have your doctor complete the enclosed physician form (unless
the school nurse already has this years form on file). Also, complete #1 below about prescriptions. If you have any
questions or need more physician forms, contact Mrs. Riggin-Jay, RN, 781-393-2228. The nurses fax number is
781-395-8168. Doctors may fax the information on their own forms.
--If your child needs non-prescription medication such as Tylenol, Ibuprofen, Dramamine, or Benadryl, complete
section #2 below about non-prescription medicines.
--The parent or an adult authorized by the parent needs to bring all medications to the nurse by Friday, May 15.
Any medicine, prescribed or non-prescription, must be in its original pharmacy bottle or box. Opened and
partially full bottles are fine. Please call before you come. DO NOT SEND MEDICATION WITH STUDENTS.
--An adult can pick up any leftover medications from the nurse during the school day June 8 - 12.
Please keep the top of the form and return the signed bottom half to the Andrews nurse by May 15.
Tear here Tear here
My child (name)___________________________________ has the following medical conditions: none__

#1. My child should be given these prescription medication(s) during June 5 - 7, 2015:
____________________________________________________
I want the teachers on the Field Trip to give my child the prescribed medicine. I have given the Andrews school
nurse the completed physician order form(s). I or another adult will bring the medicine in its prescription bottle to
the nurse by May 15. I understand she will instruct the teachers about giving my child the medicine on the trip.
And/Or
#2. I want the teachers on the Field Trip June 5 - 7, 2015, to give my child non-prescription medication(s). I or
another adult will bring the pharmacy bottle(s) to the Andrews nurse by May 15.
a. Name of medicine_______________________________
Reason to give medicine_______________________________________
Number of milligrams per pill ________
Number of pills per dose _________
How often my child can get this medicine _________________________________
b. Name of medicine_______________________________
Reason to give medicine_______________________________________
Number of milligrams per pill ________
Number of pills per dose _________
How often my child can get this medicine _________________________________

Signature of Parent/Guardian__________________________________Date

_______

Prescription medications for OVERNIGHT FIELD TRIP JUNE 5 7, 2015

MEDFORD PUBLIC SCHOOLS
Medford, Massachusetts
Medication Order Form to be completed by a licensed prescriber
Name of Student_______________________________________Date of Birth __________________
Address______________________________________________ Grade___________________
Street
(city/town)
Name of Licensed Prescriber _______________________________ Title ___________________
Business Telephone Number ___________________________
Emergency Telephone Number _________________________
Medication_________________________________________________________________________
Route of administration____________________________________ Dosage__________________
Frequency_______________________Time(s) of Administration______________________________
Specific directions or information for
administration:______________________________________________________________________
Date of Order ____________________________ Discontinuation Date________________________
Diagnosis*__________________________________________________________________________
Any other medical conditions(s)*________________________________________________________
Optional Information
1. Special side effects, contraindications, or possible adverse reactions to be
observed:_______________________________________________________________________
2. Other medication being taken by the student:______________________________________
__________________________________________________________________________________
3. The date of the next scheduled visit or when advised to return to
prescriber:________________________________________________________________________
__________________________________________________________________________________
4. Consent for self administration (provided the school nurse determines it is safe and appropriate).
Yes________ No___________

* if not in violation of confidentiality

_________________________________________________
Signature of Licensed Prescriber:
Date: _____________________________