CATHERINE M. McGEE MIDDLE SCHOOL

WASHINGTON D.C. FIELD TRIP

STUDENT MEDICAL INFORMATION

 TO WHOM IT MAY CONCERN:

 I give my permission for______________________________________________________to travel to Washington , D.C. for the 8^th                                  (Name of Student)

grade field trip during the week of April 15 through April 18, 2008 .  I hereby authorize Brian Benigni , Principal or his designee, officially named chaperones, and designated medical chaperones to treat the above named student in case of illness, or any medical emergencies or accidents.

This form must be returned notarized  by October 9, 2007.

 In addition, I understand and agree that should the student’s behavior violate school regulations seriously enough to warrant being sent home before the end of the trip, I will be held responsible for those additional travel expenses. 

Parent/Guardian Name__________________________________________________________________________________________

Insurance Company____________________________________________________________________________________________

Policy #________________________________________________

Where parent/guardian can be reached in any emergency:

__________________________                            ______________________________        _____________________________

 Home Address                                                       Business – Co. Name                                    Cell Phone #

__________________________                            _______________________________     ______________________________

Home Phone #                                                        Business Phone #                                                    Beeper #

Please list the appropriate telephone numbers in the event of an emergency so that chaperones may contact you.  In the event you cannot be reached, please list two other adults who we may contact.

EMERGENCY CONTACTS

NAME                                                                                    PHONE                                  RELATIONSHIP

1.                                                                                                                                                                                                            

2.                                                                                                                                                                                                            

Doctor’s name and phone# 

__________________________________________________________________________________

Date of child’s last tetanus shot?________________________________

Does your child have allergies?     Yes___  No___                 

If yes to what?                                                                                       

MEDICATION AUTHORIZATION

When your child goes to Washington , D.C. , a nurse, designated medical chaperones, or school personnel will be responsible for keeping and dispensing all medications.  Students are not to carry any medication for which there is no written permission.

The following non-prescription medications have been approved to be administered as needed.

May your child be given the following, if needed?

                *              Tylenol – 650 mg. every 4 hours, for fever, headache or pain                               yes__ no__

                *              Ibuprofen – 200 mg 1 to 2 tabs every 6 hr. for headache, muscle pain                  yes__ no__

                *              Pepto-bismol – 2 tablets for nausea, vomiting, or diarrhea                                    yes__ no__

                *              Dramamine – 50-100 mg. every 4-6 hrs, for motion sickness                                yes__ no__

                *              Tums – 2 tablets every 4-6 hrs, for indigestion                                                      yes__ no__

                *              Robitussion cough syrup – 2 tsp. Every 4 hrs. (max. 12 tsp.                                  yes__ no__

                                                in a 24 hr period) for persistent cough

                *              Benadryl 25 – 50 mg. every 4-6 hrs. for hives or minor allergic                             yes__ no__

                                                reaction

                *              Sudafed – 2 tablets every 6 hrs. for nasal congestion, not to                                 yes__ no__

                                                exceed 8 tablets in 24 hrs.

                *              Chloraseptic spray PRN for sore throat                                                                yes__ no__

NOTE: If your child needs medications while in D.C. other than those listed above, you will need to complete a medication authorization form which contains the physicians medication order and your signature permitting your child to receive the medication.  If your child takes medications, inhalers or nasal sprays daily that they will require while in D.C., please list the name, dose, and frequency for each below.

PRESCRIPTION MEDICATIONS                                      DOSAGE                                                FREQUENCY

Please list below any other comments about your child’s health that might be helpful to the chaperones to know

Parent or Guardian Signature

STATE OF Connecticut   )              

                                                )               BERLIN

COUNTY OF Hartford           )

Personally appeared,________________________________signer and sealer of the foregoing instrument and acknowledged the same to be his free act and deed before me this____day of_________, _______.

                                                                                _________________________________(signature)

                                                                                My commission expires_______________(date)

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