Overnight Field Trips
Receive Notifications
The 7th grade overnight trip to Fairview lakes will be held on June 1st and 2nd. Any medications that are required for your child to attend this trip must be held and administered by the School Nurse. No child is allowed to self-administer medication, unless it is an inhaler or Epinephrine injection, and they have orders from their physician indicating that self-administration is allowed.
Some children may take medications at home, that are not already on file in the nurses office. If that is the case, and your child requires a medication in the evening or first thing in the morning, then the medication in it's original container, accompanied by a physician's order are required. This medication is due in the School Nurses' by May 26th for the 7th grade overnight trip.
The 8th grade overnight trip will be held on June 1st and 2nd. Any medications that are required for your child to attend this trip must be held and administered by the School Nurse. NO child is allowed to self-administer medication, unless it is an inhaler or Epinephrine injection, and they orders from their physician indicating that self-administration is allowed.
Some children may take medications at home, that are not already on file in the nurses office. If that is the case, and your child requires a medication in the evening or first thing in the morning, then the medication in its original container, accompanied by a physician's order are required. This medication is due in the School Nurses' office by May 26th, for the 8th grade trip.
Warren Middle School
Over Night Medication Administration Authorization Form
This order is valid only for the school year (current) 2016-2017
This form must be completed fully in order for the nurse to administer any required medication to a student. This form must be completed by your physician. Medication cannot be administered by law without a physician’s prescription.
- Prescription medication must be in the original container labeled by the pharmacist or prescriber.
- Non-prescription medication must be in the original container with the label intact.
- An adult must bring the medication to the school health office by.
- The School Nurse will call the prescriber, as allowed by HIPAA, if a question arises about the child and/or the child’s medication.
- The School Nurse cannot by law administer any medication without a Physicians order.
Prescriber’s Authorization
Name of Student :_____________________________Date of Birth ___________________Grade____________
Medication Name :__________________________________Route ______________Dosage_________________
Time/Frequency of administration:________________________________________________________________
If PRN (as needed), for what symptoms____________________________________________________________
Prescriber’s Name/Title:__________________________
|
|
Telephone:___________________ FAX______________
Address:_______________________________________
Prescriber’s Signature:_________________ Date:_______
(Original signature or signature stamp ONLY)
(Use for Prescriber’s Address Stamp)
Parent/Guardian Authorization
I/We request designated school personnel to administer the medication as prescribed by the above prescriber. I/We certify that I/We have legal authority to consent to medical treatment for the student named above, including the administration of medication at school. I/We understand that at the end of the school year, an adult must pick up the medication, otherwise it will be discarded. I/We authorize the school nurse to communicate with the health care provider as allowed by HIPAA.
Parent/Guardian Signature_______________________________________________Date:______________________
Home Phone #________________________Cell Phone #________________________Work Phone #_____________
Order reviewed by the School RN:_____________________________________________________________________
Signature Date
- Please refer to the Warren Board of Education Policy on Medication Administration File Code 5141.21 on the Warrentboe.org website for further information regarding the administration of medication in schools.
LL/2010
Contact Us
