Date _______________________________

Dear Parent/Guardian of Overnight Field Trip Students:

In order for the school to administer medication during an overnight field trip, the following procedure needs to be followed:

1. A completed "Request for Medication Administration during School Hours" form must be on file in the office. Both Part A (by your physician) and Part B (by parent/guardian) must be completed for prescription medication. Only Part B (by parent/guardian) is necessary for non-prescription medications.

2. If your child currently takes medication during school hours, a new form needs to be filed since the medication may be given at other times or your child may take additional medications.

3. A separate form must be on file for each medication your child will be taking. Additional forms are available in the office if needed.

4. The medication must be in the original pharmacy container and properly labeled.

5. Please read and be aware of the medication policy on the reverse side of the form.

Please provide this information prior to the field trip; otherwise, your child will not receive his/her medication.


___________________________________________________, R.N.


(Page 2)


1. Distribute cover letter and "Request for Medication Administration during Overnight Field Trip" forms to students at least two weeks before the trip. Collect completed forms and turn them in to the school nurse or office secretary as soon as possible.

2. Review medication administration procedure, and students with special medical need list with school nurse before field trip.

3. Take the following items on the field trip:

  • Medication administration forms
  • Medications
  • Medication log
  • Emergency/Health Forms
  • First aid kit

4. Return all of the above to the office upon return to the school. Notify school nurse of any medication or student health problems occurring on the field trip.


(Page 3)


Prescription/Medication: Physician to complete Part A. Parent/guardian to complete Part B. Return form to school. Additional forms available at the school office,

Non-prescription Medication: Parent/guardian to complete Part B only.

PART A (One medication per form)

Notice to school employees administering medication as designated by school officials to provide the following medication to the student as directed below.

Student name______________________________




Time(s) administered______________________________

Reason for medication______________________________

Student may carry medication for emergency purposes ___Yes ___No

Give medication on ___ empty stomach ___ full stomach

Refrigerate medication ___Yes ___No

Additional directions or symptoms to report______________________________

PRN medication/circumstances to be used______________________________

NOTE: Designated school staff who dispense medication to the above student may call me at any time with questions or concerns related to this student's medical condition and medication.

Doctor's Signature____________________________________________ Date _______

Doctor's Name (Please Print) ________________________________________________

Address_______________________________________________ Phone ____________

PART B (One medication per form)

I hereby give permission to school employees designated by school officials to give medication to my child according to the following direction. I further give permission to school authorities to contact my student's physician as necessary and to notify the school in writing at the termination of this request or when any medication changes occur.

Student name ______________________________Grade_____

Name of medication______________________________

Dosage to be given______________________________

When to be given and how often______________________________

Reason for medication______________________________

Additional information______________________________

I have read the Medication Criteria for Dispensing Medication at school on the back of this page and agree to meet this criteria. ALL medication must be in a properly labeled container.

Parent Signature _________________________________________ Date_______________

Daytime Telephone Number__________________________________________


(Page 4)


1. Pupils requiring medication at school shall bring to the school principal or designee, a completed "Request for Medication Administration During School Hours" form signed by the physician and parent/guardian if a prescription medication or the parent/guardian if a non-prescription medication. School personnel may then administer medication to the child as prescribed. All medication authorization forms must be renewed annually.

2. ALL medication must be supplied in the original container that is labeled for school authorities. The label on the bottle must contain the name and telephone number of the pharmacy, the pupils identification, name of the physician, medication name, number dispensed, strength, dose, route, times or circumstances for medication to be given, special directions for storage or dispensing. Non-prescription medication must be in the original container with the directions on the container including pupil's name. The prescribed medication shall be kept in a locked cubicle or drawer. Taking the medication shall be supervised by the designated school personnel at a time conforming with the indicated schedule. It is the responsibility of the student to get his/her medication at a designated time.

3. It is important that an accurate and confidential system of record keeping be established for each pupil receiving medication. The physician's request for medication to be administered during school hours shall be kept on file. The parents must notify the school when the drug is discontinued or the dosage or time is changed. An updated medication authorization form is required for ALL changes in medication.

4. It is the responsibility of the parent/guardian to provide and deliver to the school all authorized medication and replace expired medication. Any special circumstances regarding delivering medication to school must be sanctioned by the school principal. All unclaimed medication, at the end of the school year will be disposed of per policy, after written notification to the parent/guardian.

5. School personnel should, under no circumstances, provide any medication to students without meeting the criteria in, 1 to 4 above. Diagnosis and treatment of illness and the prescribing of medication are never responsibilities of a school and should not be practiced by any school personnel.

6. It is the responsibility of the parent/guardian to notify school personnel of pertinent medical information regarding their child. Pupils with a potential life threatening health problem may be excluded from school until required medication and staff training are in place at school.