Overnight Medication Form

Parents,

Please fill out the Medication Form below and return the morning of our departure in a Ziploc bag enclosed with any medications your child will need on the trip.  

If you are unable to print the document, please let me know and I will send one home with your child (gtaft@tescharlotte.org).

11 days and counting...

OVERNIGHT MEDICATION FORM

Allergic Reactions and Epi-pens

As a result of the increased number of children with allergies to a wide variety of substances including food and insect bites, Trinity will now be sending an Epi-Pen in the first aid kit on overnight trips. 

An Epi-Pen is a pre-loaded injection of epinephrine which is given to an individual only when they are having a severe allergic reaction involving swelling and difficulty breathing.  It can be a life-saving measure until emergency help can arrive. The faculty and staff have been instructed in the use of the Epi-pen.

Your signature below gives Trinity Episcopal School your permission to administer the epinephrine in the event that your child has a severe allergic reaction.

I give my permission for the faculty, staff, or chaperones to give my child(ren) _____________________________________ an injection of epinephrine by using the Epi-pen in the event of a severe allergic reaction.

I do not give permission for the faculty, staff, or chaperones to give my child(ren)_____________________________ an injection of epinephrine by using the Epi-pen in the event of a severe allergic reaction.

_______________________________                ____________________________

Parent’s Signature                                                                     Date

__________________________________________________________________

Prescription Medication

Student: _______________________________________Grade: _______Date: ____________

Name of Prescription #1 _______________________ Dosage amount and time:_____________

Name of Health Provider ___________________ Phone: _______________________

Name of Prescription #2_______________________ Dosage amount and time:____________

Name of Health Provider:____________________Phone______________________

Special information or details:

Please remember to send the prescription medication in the container given by pharmacy and enclose in plastic bag along with this form.  Thanks!