ALL ABOUT BAND (Part 6) 7-2-12 Health Form Part 2

Permission for Giving Prescription and Over the Counter Medications

I would like designated chaperones to administer my child’s prescription medication.

Medication(s) and time(s) to be given:

I give permission for designated chaperones to administer prescription medication to (student name)________________________________.

Parent Signature____________________________________________

Date______________________

______________________________________________________________________-________

Chaperones will carry a limited supply of over the counter medications during this trip. Permission needs to be given to administer these medications. (Please note that chaperones may not have  what your child is taking at home.)

I give permission for designated chaperones to administer over the counter medication as necessary to my child (student name)___________________________________________

Parent Signature_________________________________________________

Date______________________

My child will be carrying and administering his/her own prescription and or over the counter medication.

Medication with student (please list):

I give permission for my child (student name) ________________________________________to self administer his/her own over the counter and or prescription medication.

Parent Signature____________________________________________

Date_________________________________________________

Please note any prescription medication must be in a container in which it was dispensed by prescribing physician and licensed pharmacist.