SAN ANTONIO INDEPENDENT SCHOOL DISTRICT

STUDENT HEALTH SERVICES DEPARTMENT

OVERNIGHT TRAVEL MEDICATION PERMISSION FORM

Please review and sign below indicating the medication permissions you give for your student while on
overnight travel with San Antonio ISD.

Students are not allowed to carry any medications on their person, including non-prescription medications,
unless written permission has been provided by a physician and parent for certain medications (see below).
Medications not permitted to be self-carried will be maintained and dispensed by District staff.

MEDICATIONS: All medications must be brought by the students parent/guardian to the designated District
employee responsible for the administration of the students medication(s). Medications must be in the original
container or prescription bottle with proper labeling.

Medication #1:
Name Dose Time(s) Route

Medication #2:
Name Dose Time(s) Route

Medication #3:
Name Dose Time(s) Route

Medication #4:
Name Dose Time(s) Route

EMERGENCY MEDICATIONS/DIABETIC MEDICATIONS AND SUPPLIES: Inhalers, Epinephrine

auto-injectors, Glucagon kits, Insulin and diabetic supplies are to be provided by the students parent/guardian
in the correctly labeled prescription container. Self-carry permission forms already signed by the physician and
parent and previously submitted to the campus clinic may be obtained from the campus clinic nurse.

NON-PRESCRIPTION STOCK MEDICATIONS: The following non-prescription medications will be

available for minor symptoms in accordance with dosages prescribed by the manufacturer. Unless listed below,
no other non-prescription medications will be administered.

Parent/guardian authorization must be indicated for each medication listed below. No signature will be
interpreted as no authorization.

MEDICATION PURPOSE AUTHORIZATION PARENT/GUARDIAN

Yes No SIGNATURE
Tylenol/Acetaminophen Fever/Pain Relief
Advil/Ibuprofen Fever/Pain Relief
Benadryl/Diphenhydramin Mild Allergy
e Hydrochloride
Imodium AD/Loperamide Antidiarrheal
Hydrochloride
I, , give permission for my child to receive the above
medication(s)

Printed Name
as directed. I understand the procedures for the dispensing of non-prescription, prescription, and emergency
medications while my student is on overnight travel with SAISD.

Signature of parent/guardian: Date:

Name of student: Date of Birth:

School: Grade: ID#: _

H-831A Oct. 2016