Gloucester county institute of technology

INSTITUTE OF TECHNOLOGY

Pride

Responsibility

Six Flags Great Adventure, Jackson, NJ

May 26, 2009

a. Deemed as under the influence of alcohol or illegal drugs just before leaving

the trip.

b. Caught with illegal substances before leaving for the trip.

THE FOLLOWING GENERAL PRINCIPLES WILL BE INSISTED UPON:
1. Complete cooperation with the chaperones. Chaperones are designated by the school and will

have full charge of the students. Every student must cooperate with the chaperones to the fullest extent.

1. 
   Name of student:
   

3. 
   Address:
   

4. Date of last Tetanus Booster:

5. Known allergies: (i.e., Penicillin, foods, etc.)

6. History of past or present medical conditions that may affect treatment:

7. 
   Medical Insurance (Policy number must be listed.)
   

Policy Number: I have no medical coverage:

7. 
   Family Doctor: Phone #:
   

GLOUCESTER COUNTY INSTITUTE OF TECHNOLOGY

Sewell, New Jersey 08080

POLICY ON SELF-ADMINISTRATION OF MEDICATIONS

IN SCHOOL AND ON SCHOOL-SPONSORED TRIPS

Due to the need for certain students to carry and self-administer potentially life-saving medication in school and/or on a school-sponsored trip, the following district policy will govern this:

1. 
   Written certification of the student’s illness, the name of the medication, dosage and time of administration and length of time medication to be taken must be provided to the school by the student’s physician. The physician will also certify, in writing, that the student is capable of and has been instructed in the proper administration of the required medication.
   

2. 
   The parent/guardian must provide to the school written authorization for the administration of the medication. The parent/guardian will also sign a statement releasing the school from any responsibility for any injury or claim that may arise as a result of the student’s self-administration of medication.
   

3. 
   The Board of Education will inform the parent/guardian in writing that the district shall incur no liability as a result of any injury arising from the self-medication. This can be accomplished with a letter from the school explaining this policy.
   

4. 
   On a school-sponsored trip, a student may carry on his/her person an inhaler for the treatment of asthma or an insect/bee sting kit for a life-threatening allergic reaction. Otherwise, the instructor/supervisor will hold the medication for the duration of the trip, but it will be the student’s responsibility to take the medication as directed by his/her physician.
   

5. 
   Permission for medication self-administration will be effective for the school year for which it is granted and must be renewed annually.
   

6. 
   This policy will also cover any over-the-counter medication that may need to be taken on an as needed basis on school-sponsored trips.
   

SCHOOL-SPONSORED TRIPS/I/POLICY

Board of Education Approved 9/5/74

Revised 9/26/91, 5/30/95, 4/24/01, 7/19/01

GLOUCESTER COUNTY INSTITUTE OF TECHNOLOGY

1360 Tanyard Road, Sewell, NJ 08080

Request Form for Administration of Medication to Student

Name of Student Shop/Program am / pm

Physician’s Name (Print)

Signature Date

Signature Date

(over)

____ Life threatening medication (i.e. inhaler or epinephrine) to be self-administered by child in school.

Signature Date

____ Medication to be self-administered by child on school-sponsored trip

I give permission for my son/daughter _____________________________ to take his/her medication while on the ______________________________ school-sponsored trip.

I understand that the medication must be in the original container and appropriately labeled by the pharmacy or physician. Except in the case of an inhaler or an insect/bee sting kit, I understand that the instructor/supervisor will hold the medication for the duration of the trip, but it will be my child’s responsibility to take the medication as directed by our physician.

Signature Date

------------------------------------------------------------------------------------------------------------------------------------------------------------

Complete only if child is administering own medication.

Indemnification/Hold Harmless Agreement

for

Student Self-Administration of Medication

We, the parents/guardians of _____________________________________ hereby acknowledge and agree that the Gloucester County Vocational-Technical School District shall incur no liability as a result of any injury arising from the self-administration of medication.

We further agree that, pursuant to N.J.S.A. 18A: 40-12.3 (d), we shall indemnify, hold harmless, and defend the Gloucester County Vocational-Technical School District, its employees and agents, from and against any and all costs, expenses (including reasonable counsel fees), liabilities, judgments, losses, damages, suits, actions, fines, penalties, claims, or demands of any kind and asserted by or on behalf of any person or entity arising out of or in any way connected with the self-administration of medication by .

Parent/Guardian Signature Date

10.10.3.7.1  REQUEST FORM FOR ADMINISTRATION OF MEDICATION TO STUDENT