Travel Consent/health Form With Medication Addendum To Travel Consent/health Form
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1
2North East Independent School District
10333 Broadway – SAN ANTONIO, TEXAS 78217
CONFIDENTIAL
Phone (210) 356-9244, Fax (210) 657-8677
Medication Addendum to Travel Consent/Health Form
Department of
Health Services
Permission for the Dispensing of Non-Prescription Medications: Medication for minor symptoms
will be dispensed in accordance with dosages prescribed by the manufacturer. Dosages of other items or
beyond what is prescribed on the packaging will not be administered.
Authorization of each must be indicated with the parent/guardian signature. No signature will be
interpreted as disapproval.
Medications
Purpose
Authorization
Parent/Guardian Signature
Tylenol/Acetaminophen
Fever/Pain Relief
Yes
No
Advil/Ibuprofen
Fever/Pain Relief/
Anti-Inflammatory
Yes
No
Benadryl/
Mild Allergy
Diphenhydramine Hydrochloride
Yes
No
Imodium AD/
Antidiarrheal
Loperamide Hydrochloride
Yes
No
Tums/Calcium Carbonate
Indigestion/Antacid
Yes
No
Medications: All medications for individual students that must be taken must be brought by the
student’s parent/guardian to the authorized and trained district employee or authorized and trained
parent (RN, LVN, MD, PA, Pharmacist) responsible for the student’s medication. Medications must be
in the original container or prescription bottle with proper labeling. All medication must have a note
from the parent with specific directions in regard to dosage and times of administration. No student
may have any medications (Prescription/Non-Prescription) on their person except as described
below.
Emergency Medications/Diabetic Medications and Supplies/Prescription Birth Control
Medications: Inhalers, Epipens, Glucagon Kits, Insulin and diabetic supplies or other emergency
medications and prescription birth control medications are to be provided by the parents in the correctly
labeled prescription container. If requested, permission for students to carry these medications for self-
administration must have written physician and parent authorization. New or completed forms that have
already been submitted for this purpose at school may be obtained from the RN.
An authorized and trained district employee or authorized and trained parent (RN, LVN, MD, PA,
Pharmacist) will administer all medications not authorized for self-administration. Documentation of
dates and times of administration and signatures of the authorized and trained district staff or authorized
and trained parent (RN, LVN, MD, PA, Pharmacist) will be kept on an official NEISD Travel
Medication Record.
I hereby certify that I fully understand the procedures/permission for the dispensing of Non-Prescription/
Prescription Medications.
Student Signature______________________________________ Date___________________
Parent/Guardian Signature______________________________ Date___________________
7/14
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