North Florida 2026 Medical Form
Please submit this form by Thursday, October 1.
Student's name
*
First Name
Last Name
Does your child have any dietary restrictions?
*
No
Yes - Please add dietary restriction below
Dietary restrictions
*
Medical conditions
*
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."
Medication your child will be bringing on the trip
*
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. If your child is not bringing any medications, please indicate "None."
Who should administer the medication(s) your child is bringing?
*
Child may self administer medications
Chaperone or trip nurse should administer medications
Child is not bringing any medications
Medication labeling
*
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.
Permission to dispense over-the-counter medications
*
Tums (Antacid)
Benadryl (Diphendydramine)
Tylenol (Acetaminophen)
Advil/Motrin (Ibuprofen)
Dramamine (Dimenhydrinate)
None
Medical release
*
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 in FACTS. If I cannot be reached, I hereby authorize a teacher or group leader to make emergency medical decisions for my child.
Name of parent/guardian submitting form
*
First Name
Last Name
Email address of parent/guardian submitting form
*
example@example.com
Submit Medical Form
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