Medication Form
In trying to be in accordance with Chesapeake Public Schools medication administration policy, I am asking that each student attending the Spring Orchestra Trip complete the following form. If your child does not take any medicines, then please select “NO” on the form and sign and submit. If your child takes multiple medications, please fill out a new form for each medicine for records purposes. We appreciate your help with this matter. Medicine should be in original container that lists students name, dosage and times for administration.
Student Name
*
First Name
Last Name
Parent/Guardian Name
*
First Name
Last Name
Parent Email
*
example@example.com
Parent Cell
*
Please enter a valid phone number.
Format: (000) 000-0000.
Does the above student require medication?
*
YES
NO
Medicines your student takes daily
*
Frequency of Medications
*
Dosage
*
Parent/Guardian Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
*
I give Mr. LJ Kuskowski permission to administer my child’s medication to him/her while on the 2026 Atlanta trip from April 16-19, 2026.
Parent Signature
*
Student Signature
*
Submit
Should be Empty: