Field Trip Health and Medication Form - Devon Preparatory School

Please note that the form is valid for the duration of one school year and that the completion of a new form is required prior to the start of each new school year and when there is a change in your son’s health history.

Student's First Name*

First

Student's Last Name*

Last

Date of Birth*

Grade*

Parent / Guardian Name*

First Last

Parent / Guardian Email

Home Phone Number*

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Father's Cell / Home Phone*

Father's Work Phone

Mother's Cell / Home Phone*

Mother's Work Phone

Please check if student has had a history of:

Diabetes
Seizures
Heart Condition
Ear Condition
Asthma
Hemophila
Other (please specify condition below)

Please specify condition.

Please list all medications being taken:

Please choose one option:

My child will not be taking the above medication(s) during this trip.
I will supply medication(s) and physician’s order to a staff member who is accompanying the group. My child may take his medication supervised by a staff member.

Treddyffrin/Easttown School District requires that a physician’s order accompany ANY PRESCRIPTION OR OVER-THE-COUNTER MEDICATION that is provided to a student by a staff member. Students are not permitted to carry a medication unless it is needed for a life-threatening condition. The physician’s order must indicate the child’s name, the name of the medication, dosage, route of administration, and the time or circumstance under which the medication should be given. The medication must be in the original container. If a nurse is present, Advil can be given. If a nurse is not present, Advil can only be given if a physician’s note had been provided to the school. The note is valid for the duration of one school year.

The doctor's note in a form of a JPEG or PDF can be uploaded here.

Max. file size: 5 MB.

Specify any known allergies to drugs, insect bites, food, or substances:

History of past illness(es) that may affect emergency treatment:

If the school nurse IS A CHAPERONE on the field trip, the medications below will be supplied and your son does not need a doctor’s note for these medications. However, we require parental permission to give the medication. DO NOT SEND THESE or any non-essential medication. Check all medications your son may or may not be given. If there is NOT a school nurse on the field trip, the only medications supplied will be benadryl, tums, and cough drops. Your son may bring an inhaler and/or EPI-pen without a doctor’s note. All other medications must be supplied by you and must be accompanied by a doctor’s note.

Advil*

Tylenol*

Throat Lozenges*

Benadryl*

Date*

Signature of Parent / Guardian*

Phone

This field is for validation purposes and should be left unchanged.