MMUN | New York Marriott Marquis, NYC, NY | 3/20/2024 - 3/23/2024

Please complete this form and provide all medications to the School Nurse by Tuesday, 3/11/24.

Student's First and Last Name(s) *

Student DOB * +

Health Concerns

Allergies *

Yes

If yes, please list allergies.

Epinephrine *

Yes

Asthma *

Yes

Special Diet *

Yes

Specify

Please list any other health diagnoses.

Medications

List all medications (including over-the-counter medication (OTC)) needed for the duration of the field trip. A physician's order is required for prescription, over-the-counter, topical, and herbal medicines.

- Please send only medications that are regularly taken by the student and are medically necessary.

- Only send the amount of medication needed for the trip.

- All medications must be in a pharmacy-labeled container, with name, medication, dosage, and frequency of administration. A physician's order is required if medication is taken differently than listed on the pharmacy label or for OTC/Herbal medications. Please indicate if medication should be given at breakfast, lunch, dinner, or bedtime.

- Students who keep an Epi-pen and/or Inhaler at school do not need to send additional medication as the ones we have in school will accompany the student.

Upload physician's order(s).

Health Insurance

Health Insurance Provider *

Policy Number *

Primary Subscriber of Medical/Health Policy *

Student's Primary Health Care Provider *

Phone Number *

Emergency Contacts

First Name *

Last Name *

Best Contact Number *

Alternative Contact Number

Email Address *

First Name

Last Name

Best Contact Number

Alternative Contact Number

Email Address

First Name

Last Name

Best Contact Number

Alternative Contact Number

Email Address

Electronic Signature

This form serves as parental/guardian consent for the MMUN field trip to New York City for March 20 to March 23, 2024. I acknowledge that any medications, prescriptions, over-the-counter, or herbal received the day of the field trip will not be provided and must be brought to the school nurse no later than March 5, 2024. If Medications already stay at school (such as Epi-pen, Inhaler, etc.), you do not need to bring them. The school nurse will ensure all orders are up-to-date and contact you if anything is required. Designated staff will always carry all rescue medications, such as inhalers and epi-pens. Students will not be able to carry any medications with them. A medication and administration-trained Thacher staff member will dispense other necessary medications at breakfast, lunch, dinner, and bedtime as indicated on the physician's orders.

A parent or guardian must hand all medications to a Thacher staff member. Students are not to bring them in.

By signing this form, I agree to allow a Thacher staff member to accompany and seek medically necessary care for the listed student in the event of a sickness or injury.

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Parent/Guardian First & Last Name *

Date * +