Overnight Field Trip Medical Release Parent Form

OVERNIGHT FIELD TRIP MEDICAL RELEASE PARENT FORM

Questions or concerns? Contact the BACS Clinic at nurse@bacschool.org.
Student Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Grade*
Teacher
Primary Contact Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Secondary Contact Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Will your child need medication on the field trip?*

Yes, I will send it from home.Yes, the BACS Clinic already has a doctor's order on file and the medication.No
- Signature
  
  Clear
- DateTime
- NO MEDICATION
  
  I, the undersigned, will NOT be sending any medication for my child on the overnight field trip. My child has no medical conditions that the school officials need to be aware of at this time.
- Signature
  
  Clear
- DateTime
- I, the undersigned, WILL BE sending medications for my child on the overnight field trip. All medication must be brought to the school clinic. Please note:
  - Please send only the amount your student needs to take while on the trip.
  - Medication must be in the original, properly labeled container.
  - Narcotics will not be accepted as they cannot be administered.
  The medications must be picked up by the parent, legal guardian, or other person having legal control of the student upon return from the trip.
  
  By signing below, I am giving consent for the listed medications to be administered to my child by a BACS-appointed adult. I, the undersigned, understand that it is my responsibility to deliver the medication listed to the school nurse or other BACS-appointed employee as medications will not be supplied.
- Number of Meds
- Medication 1:
- Type of Medication
  
  PrescriptionNon-Prescription
- Name of Medication
- Date to Begin Medication
  
  MonthDayYear
  Date
- Date to End Medication
  
  MonthDayYear
  Date
- Time to be Given
- Amount to be Given
- Reason for Medication
- Form of Medication*
- Physician's Name
- Physician's Phone Number
  
  Area CodePhone Number
- Medication 2:
- Type of Medication
  
  PrescriptionNon-Prescription
- Name of Medication
- Date to Begin Medication
  
  MonthDayYear
  Date
- Date to End Medication
  
  MonthDayYear
  Date
- Time to be Given
- Amount to be Given
- Reason for Medication
- Form of Medication
- Physician's Name
- Physician's Phone Number
  
  Area CodePhone Number
- Medication 3:
- Type of Medication
  
  PrescriptionNon-Prescription
- Name of Medication
- Date to Begin Medication
  
  MonthDayYear
  Date
- Date to End Medication
  
  MonthDayYear
  Date
- Time to be Given
- Amount to be Given
- Reason for Medication
- Form of Medication
- Physician's Name
- Physician's Phone Number
  
  Area CodePhone Number
- Medication 4:
- Type of Medication
  
  PrescriptionNon-Prescription
- Name of Medication
- Date to Begin Medication
  
  MonthDayYear
  Date
- Date to End Medication
  
  MonthDayYear
  Date
- Time to be Given
- Amount to be Given
- Reason for Medication
- Form of Medication
- Physician's Name
- Physician's Phone Number
  
  Area CodePhone Number
- Medication 5:
- Type of Medication
  
  PrescriptionNon-Prescription
- Name of Medication
- Date to Begin Medication
  
  MonthDayYear
  Date
- Date to End Medication
  
  MonthDayYear
  Date
- Time to be Given
- Amount to be Given
- Reason for Medication
- Form of Medication
- Physician's Name
- Physician's Phone Number
  
  Area CodePhone Number
- Medication 6:
- Type of Medication
  
  PrescriptionNon-Prescription
- Name of Medication
- Date to Begin Medication
  
  MonthDayYear
  Date
- Date to End Medication
  
  MonthDayYear
  Date
- Time to be Given
- Amount to be Given
- Reason for Medication
- Form of Medication
- Physician's Name
- Physician's Phone Number
  
  Area CodePhone Number
- Medication 7:
- Type of Medication
  
  PrescriptionNon-Prescription
- Name of Medication
- Date to Begin Medication
  
  MonthDayYear
  Date
- Date to End Medication
  
  MonthDayYear
  Date
- Time to be Given
- Amount to be Given
- Reason for Medication
- Form of Medication
- Physician's Name
- Physician's Phone Number
  
  Area CodePhone Number
- Medication 8:
- Type of Medication
  
  PrescriptionNon-Prescription
- Name of Medication
- Date to Begin Medication
  
  MonthDayYear
  Date
- Date to End Medication
  
  MonthDayYear
  Date
- Time to be Given
- Amount to be Given
- Reason for Medication
- Form of Medication
- Physician's Name
- Physician's Phone Number
  
  Area CodePhone Number
- Medication 9:
- Type of Medication
  
  PrescriptionNon-Prescription
- Name of Medication
- Date to Begin Medication
  
  MonthDayYear
  Date
- Date to End Medication
  
  MonthDayYear
  Date
- Time to be Given
- Amount to be Given
- Reason for Medication
- Form of Medication
- Physician's Name
- Physician's Phone Number
  
  Area CodePhone Number
- Medication 10:
- Type of Medication
  
  PrescriptionNon-Prescription
- Name of Medication
- Date to Begin Medication
  
  MonthDayYear
  Date
- Date to End Medication
  
  MonthDayYear
  Date
- Time to be Given
- Amount to be Given
- Reason for Medication
- Form of Medication
- Physician's Name
- Physician's Phone Number
  
  Area CodePhone Number
- PARENT/GUARDIAN SIGNATURE
- Parent Name
  
  First NameLast Name
- Date
  
  MonthDayYear
  Date
- Parent Signature
  
  Clear
Should be Empty:

OVERNIGHT FIELD TRIP MEDICAL RELEASE PARENT FORM

PARENT/GUARDIAN SIGNATURE