2021-2022 Request for Medication Administration

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Please complete this form. If you wish to have the designated medications dispensed to your child when needed by a Lake Travis Band staff person, please check the appropriate boxes below. For the email address below, you must enter a parent's email address.

Email *

Student Last Name *

Student First Name *

Grade *

Date of Birth *

YYYY

Please list any allergies to medications or foods or list "none". *

What medications is your student currently taking? (Please include over the counter medications and prescription medications.) *

List below any prescription medication(s) to be dispensed while your student participates in band events (e.g. at an all-day band competition). These medications will be dispensed per instructions on the label(s) and must be turned in by the parent to a Band Director on the day of the event . If your student needs prescription medications only in the event of an overnight trip, you will have an opportunity to fill out that request prior to an overnight trip (e.g. spring trip).

In addition to standard first aid treatments (administering bandages, antibiotic ointment, antihistamine cream, Afterbite, etc.), the following medications may be given to my child if needed per recommended dosages on the labels - check all that apply. *

Acetaminophen (e.g. Tylenol)

Ibuprofen (e.g. Advil)

Anti-Motion Sickness (e.g. Dramamine, Bonine)

Midol

Anti-Diarrheal (e.g. Imodium, Pepto Bismol)

Antacid/Anti-Gas (e.g. Tums, Gas X)

Antihistamine (e.g. Benadryl, Diphenhydramine)

Cough Drops

Claritin (Loratidine)

I would prefer that my student not be given any over the counter medication.

Required

Please check each box below to indicate acknowledgement: EVERY BOX IN THIS SECTION MUST BE CHECKED FOR FORM TO BE CONSIDERED COMPLETE. *

LTHS band staff will administer medication to my child in accordance with the above information.

LTHS band staff will store all prescription medicines for the duration of band trips. Students are not allowed to store their own prescription medicine.

When traveling, all prescription medicines must be given to Mr. Trevino (Asst. Director) prior to departure.

It is the student’s responsibility to request prescription medications when needed.

Parents with concerns regarding a student’s medicine needs must speak to Mr. Trevino prior to departure.

Any changes to medical administration will require a new form to be filled out and submitted before departure.

Required

Please list parent phone number to call in case of medical question or emergency. *

Parent Signature (please type name as indication of signature). *

A copy of your responses will be emailed to the address you provided.

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