• Permission Form for Medication & Care Plan

    (FOR TRIP)

  • Part A: Medication Details

    IMPORTANT: medication must be in original container when presented to school.
  • #1 Start Date of the medicine to *
     - -
    2 digit day, 2 digit month, 4 digit year
  • #1 Stop Date of the medicine*
     - -
    2 digit day, 2 digit month, 4 digit year
  • #2 Start Date of the medicine to *
     - -
    2 digit day, 2 digit month, 4 digit year
  • #2 Stop Date of the medicine*
     - -
    2 digit day, 2 digit month, 4 digit year
  • #3 Start Date of the medicine to *
     - -
    2 digit day, 2 digit month, 4 digit year
  • #3 Stop Date of the medicine*
     - -
    2 digit day, 2 digit month, 4 digit year
  • #4 Start Date of the medicine to *
     - -
    2 digit day, 2 digit month, 4 digit year
  • #4 Stop Date of the medicine*
     - -
    2 digit day, 2 digit month, 4 digit year
  • #5 Start Date of the medicine to *
     - -
    2 digit day, 2 digit month, 4 digit year
  • #5 Stop Date of the medicine*
     - -
    2 digit day, 2 digit month, 4 digit year
  • #6 Start Date of the medicine to *
     - -
    2 digit day, 2 digit month, 4 digit year
  • #6 Stop Date of the medicine*
     - -
    2 digit day, 2 digit month, 4 digit year

  • Note: For emergency medications (e.g., inhaler, EPIPEN), it is strongly recommended to provide two units:

    • One to be kept in your child’s personal bag for immediate access.
    • One to be kept with the nurse or designated trip leader as backup.

  • Part B: Over-the-Counter (OTC) Medication Consent

    Attached is the list of over-the-counter medicines that may be used during the trip. If your child has used these before without allergic reactions, please tick your consent. If unsure or your child has medical conditions, please consult your doctor before signing.
  • Medicine Picture Use for Dosage
    Air-X   Relieves painful pressure caused by excess gas in
    the stomach and intestines.     		  1 chewable tablet 
  • AIR X
  • Medicine Picture Use for Dosage
    Paracetamol 500 mg   Relieves fever, headache, cold & flu symptoms, toothache, teething discomfort, and fever after vaccination.  Weighing 16 - 25 kg: 0.5 tablet every 6 to 8 hours
    Weighing 26 - 35 kg: 3/4 tablet every 6 to 8 hours
    Weighing > 35 kg:
    1 tablet every 6 to 8 hours
    > 16 yrs/Adult: 1-2 tablets every 4 to 6 hours
  • Paracetamol 500 mg
  • Medicine Picture Use for Dosage
    Activated Charcoal   Used as an intestinal adsorbent to treat diarrhea. Adults: 2-4 tablets, 3-4 times/day
    Children:Half the dosage
  • Activated Charcoal
  • Medicine Picture Use for Dosage
    ORS   Used for oral rehydration in cases of acute
    diarrhea and cholera.    		 Child>5yrs /Adult: Dissolve 1 packet in 150 mL or 750 mL water, drink a volume of solution as much as thirst demands.
  • ORS
  • Medicine Picture Use for Dosage
    Dimenhydrinate (50 mg) [Anticholinergics / Antihistamines /
    Dimenhydrinate]
    Prevents and treats nausea, vomiting, and
    dizziness caused by motion sickness.    		 Age 6 to 7 Years: 0.5 tablet every 8 to 12 hours
    Age 12 Years and Over: 50 mg every 8 to 12 hours
  • Dimenhydrinate (50mg)

  • Part C: Over-the-Counter (OTC) - Medicines Requiring Doctor’s Advice or Parent Supply

    (Please hand over to the nurse if provided)
  • Medicine Picture Use for Dosage
    Cetirizine (Alerest 10 mg) For allergy, urticaria, insect bites ≥6 yrs: 5–10 mg daily
  • Cetirizine (Alerest 10 mg)
  • Medicine Picture Use for Dosage
    Domperidone
    (Motilium 10 mg)    		 For nausea, vomiting, bloating ≥12 yrs & ≥35 kg:
    1 tab up to 3 times /day (before meals)
  • Domperidone (Motilium 10 mg)
  • Medicine Picture Use for Dosage
    Nurofen
    (Duran 400 mg)    		 For fever, headache, inflammation. ≥12 yrs & ≥40 kg: 1 tab every 6hrs
    (max 3 times/day)
  • Nurofen (Duran 400 mg)
  • Medicine Picture Use for Dosage
    Ponstan For pain,dysmenorrhea, arthritis ≥14 yrs: 1 tab 3 times /day (after meal)
  • Ponstan
  • Medicine Picture Use for Dosage
    Antergan Cream
    (2% w/w)    		 For insect bites, rash, irritation > 2 yrs and older: Apply to affected area 2–3
    times/day up to 3 days
  • Antergan Cream (2% W/W)

  • Part D: Care Plan (Procedure related to Health Condition)

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  • Part E: Consent

  •       (full name of parent/guardian) give permission for (name of child)   {nameOf38}      to receive the above medication at school according to standard school policy. Be cared for according to the attached care plan/procedure and have medication administered by a member of the nurse team, Bangkok Patana staff, trip leader (including the bus monitor or bus driver, if my child, who is a regular bus user, requires emergency medication to ensure their safety while travelling on the school bus). I agree to hold Bangkok Patana School staff and Board of Foundation free from all responsibility resulting from administering the above medication or following the care plan.

  • Important Note:

    Medication must not be shared with other students under any circumstance. Parents should send only the quantity of medication needed for the duration of the trip. All medicines must be in their original packaging with a clear label.
  • Format: (000) 000-0000.
  •  
  • Should be Empty: