Collinsville Public Schools Nursing and

Health Services

FIELD TRIP MEDICATION PERMISSION FORM

Request for Administering Prescription Medications to Students: Medications

must be in pharmacy container with prescription label properly affixed to the
medication. Medication will only be given according to prescription label.

_____ I request that my child be allowed to take the prescription medication,

________________ as prescribed by our physician while on the trip.

_____ I request that my child be allowed to carry and use self-administered metered
dose inhaler containing rescue medication and/or EpiPen as prescribed by our
physician.

Administration of Over-the-Counter (OTC) Medication: OTC medications must

be in the original container and administered according to the recommended dosage
instructions on the package.

_____ I give my permission for Collinsville Public School representative/sponsor to

administer:

_______ Tylenol (acetaminophen)

_______ Motrin (ibuprofen)
_______ Benadryl (diphenhydramine).

Student Name ____________________________

__________________________________
Signature of Parent/Guardian

__________________________________
Daytime Phone Number

__________________________________
Emergency Phone Number

__________________________________
Todays date