OES Permission for Administering Medications on Trips

Trip to: *

Dates: *

Complete this form if your child needs to take prescription medication or regular over-the-counter medication while on a trip. If your child needs to self-carry medication (e.g. epinephrine, inhaler), please complete the self-administration form in Magnus.

All medication must be in the original container and stored in a gallon-sized plastic bag marked with the student’s first name, last name, date of birth and grade. Please make sure the medication has not expired and that there is only enough medication for the duration of the trip and no more (applies to tablets only). We are unable to support the administration of most non-FDA approved medications and supplements while on trips.

Which division is this trip for? *

Lower School

Middle School

Upper School

Is this an overnight trip with an OES sports team? *

Yes

PRESCRIPTION medications require written instructions from a physician and written permission from the parent or guardian. This requirement is met by filling in the information below and bringing the medicine in the original pharmacy container labeled with the child’s name, dosage and frequency to be given.

NON-PRESCRIPTION medications require only written permission from the parent or guardian. This requirement is met by filling in the information below. Medication must be in the labeled commercial container.

Student First Name: *

Student Last Name: *

Birthdate: * +

Grade (number only): *

Medication #1

1. Name of medicine: *

1. Dosage (# of tablets or tsp):

1. Frequency:

1. Medical condition for which this treatment is given:

1. Dates to be administered:

1. Scheduled time to be administered:

1. (check the box)

As needed only

Medication #2

2. Name of medicine:

2. Dosage (# of tablets or tsp):

2. Frequency:

2. Medical condition for which this treatment is given:

2. Dates to be administered:

2. Scheduled time to be administered:

2. (check the box)

As needed only

Medication #3

3. Name of medicine:

3. Dosage (# of tablets or tsp):

3. Frequency:

3. Medical condition for which this treatment is given:

3. Dates to be administered:

3. Scheduled time to be administered:

3. (check the box)

As needed only

Medication #4

4. Name of medicine:

4. Dosage (# of tablets or tsp):

4. Frequency:

4. Medical condition for which this treatment is given:

4. Dates to be administered:

4. Scheduled time to be administered:

4. (check the box)

As needed only

Authorization and Electronic Signature

Oregon Episcopal School has my permission to administer the above medications to my child accroding to the above instructions as indicated by my electronic signature below:

Parent/Guardian Signature (Please type first & last name): *

Date (MM/DD/YYYY): * +

Please provide an email address where you will receive a copy of the completed form *