6th Grade Williamsburg & DC Trip Medical Form

Please submit medical form by Friday, March 14.

Student's name * Required
First Last
Student's Date of Birth * Required
Month
Day
Year
Student Medical Information
Permission to Dispense Over-the-Counter Medications * Required
TGS will provide the following over-the-counter medications to be administered by the trip nurse (or a chaperone) on an as-needed basis. Please check the boxes below to give your consent for the medication to be dispensed to your child. If you do NOT want a medication dispensed to your child, leave the box unchecked.
- Tums (Antacid)
- Benadryl (Diphendydramine)
- Tylenol (Acetaminophen)
- Advil/Motrin (Ibuprofen)
- Dramamine (Dimenhydrinate)
- None
Medical Conditions * Required
Please list any medical conditions (including allergies) that chaperones and physicians should be aware of before treating your child. If there are none, please indicate "None".
None
Medications your child will be bringing on the trip * Required
Please list any prescription or over-the-counter medications you are sending with your child on the trip. Please state the name of the medication, the dose, and when it should be administered to your child. All supplied medications will be administered by the trip nurse. If your child is not bringing any medications, please indicate "None".
None
Medication Labeling * Required
- I understand that prescription medications must be in their original container including the pharmacy label with the child's name and dosage instructions.
  I understand that over-the-counter medications must be in their original container and labeled with the child's name.
Medical Release * Required
- If my child has medical conditions which may be relevant to a physician in the event of an emergency, I have listed them above. In the event an emergency occurs, I may be reached at the telephone number on record. If I cannot be reached, I hereby authorize a teacher or group leader to make emergency medical decisions for my child.
Name of Person Submitting Form * Required
First Last
Email address to confirm receipt of this form * Required
Enter Email Confirm Email
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6th Grade Williamsburg & DC Trip Medical Form

Student Medical Information

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