Microsoft word - eighth grade trip medical permission forms 2-6-12

MONTVILLE TOWNSHIP PUBLIC SCHOOLS HEALTH SERVICES
Cedar Hill: 331-7130 Valley View: 331-7100 ext. 1410
Hilldale: 808-2042 William Mason: 331-7137
Lazar Middle: 331-7100 ext. 2315 Woodmont: 808-2032
Lazar Nurse’s Fax: 973-334-1033 Montville High: 331-7100 ext. 2609/2610
February 6, 2012
Dear Parents/Guardians,
As you know, the Eighth grade trip is coming up and many of the details are being finalized. Please review, fill
out and return the Medical Overnight Trip Permission Form enclosed. If your student will require any
medication while on the trip, the separate form: “Authorization to Administer Medication” must be filled out
and signed by your student’s doctor and a parent/guardian. This includes any over the counter medication, (i.e.:
Advil, Tylenol, Zyrtec, etc.) as well as prescription medications that your student takes on a regular basis. A
separate form must be filled out for each medication.
Medications will be collected at the Health Office from June 4th through June 6th, 2012. All medication must be
delivered to the Health Office by the day before the trip, June 6th, in the original container, labeled with your
student’s name and the name of the medication. Any over the counter medication must be in a new, unopened
container, also labeled with your student’s name. No medications will be accepted the morning of the trip!

Please return the Medical Trip Permission Form and the Permission to Administer Medication Form by Friday,
March 2, 2012. If you will find it helpful, the fax number for the Health Office is 973-334-1033. If you have
any questions, please call me at: 973-331-7100 extension 2315; or you may email me at:
eleanor.klinger@montville.net. Thank you for your cooperation in this important matter.
Sincerely,
Eleanor Klinger, RN CSN
Robert R. Lazar Middle School

MONTVILLE TOWNSHIP SCHOOL DISTRICT
ROBERT R. LAZAR MIDDLE SCHOOL
MEDICAL OVERNIGHT TRIP PERMISSION FORM
STUDENT INFORMATION
Student’s Name:_____________________________________Date of Birth:_________________Age:_______ Student’s Address:__________________________________________________________________________ ________________________________________Home Phone #:______________________ Full Names of Parents/Guardians:______________________________________________________________ Parents’ Cell #s: (1)__________________________________(2)____________________________________ HEALTH HISTORY AND INSURANCE INFORMATION
Does your student have: Medical Insurance? Yes_____No_____ Prescription Plan? Yes_____No_____ Name of Insurance Company:________________________________Policy #:__________________________ Name of Prescription Plan:__________________________________ID #:_____________________________ Physician’s Name:_________________________________________Phone #:__________________________ HEALTH HISTORY:
ALLERGIES:
Please indicate dates and describe below. Please provide additional information below. __________Insect/bee sting allergy. Describe reaction __________Food allergies. Please specify. __________Medication allergies. Please specify. __________Other allergies. Please specify. ________________________________________________ ________________________________________________ ______________________________________ ________________________________________________ ______________________________________ ________________________________________________ Current Health Concerns:_____________________________________________________________________ __________________________________________________________________________________________ Date of student’s last tetanus shot:______________________________________________________________ MEDICAL OVERNIGHT TRIP PERMISSION FORM – PAGE 2
MEDICATION
Students are prohibited from carrying or self-administering any medication whether it is prescribed or over the counter while participating on a school sponsored trip as per the Board of Education policy. All such medication must be carried and administered by a Board approved licensed nurse. However, New Jersey law provides that students are permitted to self-administer medication only “for asthma or other potentially life-threatening illnesses or a life-threatening allergic reaction” N.J.S.A. 18A:40-12.5 (For example, epi-pens or inhalers.) The parent/guardian of the student must provide the school nurse with a written authorization from the student’s physician, which states that the student may self-administer these medications. This form must also be signed by the parent/guardian. Under these limited conditions, a student may self-administer only those specified medications. Please check the applicable space. If necessary, a school nurse will contact you regarding the specific
details surrounding your child.
________My student does not need any medication administered while on the trip. ________I will provide the required documentation to the school nurse in order to have my student self-administer prescribed medication. (Examples: epi-pens, or asthma inhalers only.) ________I will need the medication(s) listed below administered to my student by an approved licensed
nurse while on the trip. I understand that both my student’s physician and I must complete the
enclosed medication form.
________________________________________________________________________ ________________________________________________________________________ RELEASE OF CLAIMS
As a parent or guardian, I do hereby request and authorize the Principal to permit my student to participate in (activity)___________________________________(inclusive of customary trips in connection with such activity) during the school year__________, I understand that physical hazards may be involved in the above described activity, and I do hereby accept full responsibility for my student’s actions while so engaged in the above described activity. I hereby specifically release the Montville Township School District, its officers and members of its Board of Education, and the faculty, employees and agents of said property real or personal caused by, occurring in connection with, or arising from the above described school activity. Also, the health history is correct to the best of my knowledge and the student herein described has permission to engage in all activities, unless otherwise noted by me. I hereby authorize a school representative to stand in loco parentis for my child in the case of medical and/or dental emergencies. I give permission to the physician or hospital selected by a school representative to hospitalize, secure proper treatment for and to order medications, injections, anesthesia or surgery. I realize that all efforts will be made to contact me before any action is taken. I further understand that I am liable for all costs incurred and not covered by my insurance. I understand that this information will be shared with the medical professional attending this overnight trip. I, the undersigned, have read this release and understand all of its terms. I execute it voluntarily with full
knowledge of its significance.
Signature of Parent/Guardian____________________________________________Date:__________________ AUTHORIZATION TO ADMINISTER MEDICATION
TO A STUDENT ON A SCHOOL TRIP
To be completed by the PHYSICIAN for all prescription and non-prescription medications.
________________________________________is to receive________________________ ____________
At_________________________for the treatment of_______________________________________________ Possible Side Effects/Comments_______________________________________________________________ _________________________________________________________________________________________ How long this medication is to be given:_________________________________________________________ Physician’s Signature____________________________________________________________ Physician’s Name/Stamp_________________________________________________________ Address_______________________________________________________________________ ______________________________________________________________________________ Phone_________________________________________Date____________________________ =============================================================================== To be completed by the PARENT/GUARDIAN:
I request that the above medication, in the original container, be administered to my child. I acknowledge that the school district and its employees or agents shall incur no liability as a result of administration of this medication to my child. I give the school nurse or medical professional attending the overnight trip, permission to contact the physician and/or pharmacist with any question concerning the medication. I give my permission for relevant health information to be shared with teachers/staff/and medical professionals attending the overnight trip. PARENT’S/GUARDIAN’S SIGNATURE_______________________________________________________ STUDENT’S GRADE_______________________ Note: Medication is to be supplied in the original container. Ask your pharmacist to divide the medication into two completely labeled containers – one for home and one for school. Over the counter medications must be in new, unopened containers, labeled with the student’s first and last names.

Source: http://montville.net/cms/lib3/NJ01001247/Centricity/Domain/468/Eighth%20Grade%20Trip%20Medical%20Permission%20Forms%20%202-6-12.pdf