Student Medication Release Form 2023 Student Medication Release Form Step 1 of 6 16% Consult with your child’s physician prior to travel regarding any regularly taken medications and confirm dosage and timing (taking into consideration time zone changes in the field). Please be sure to pack any prescription or over the counter medications not listed on this form that your student may need over the course of their GO trip in a Ziploc bag labeled clearly with their name and a copy of this form. Also, ensure that any allergies or other health considerations are included in their Managed Missions profile. Minor InformationMinor's Name* First Last Goes By GO Team* GO GREECE College-Age (Billy Whitaker) GO Honduras Students (Devin Knight) GO JAARS Students (Kim Hunter) GO POLAND Students (Sean Reeder) GO RWANDA Students (Keith Page) GO Tennessee HS Students (Molly Marchese) GO Tennessee MS Students 1 (Kaleb Smith) GO Tennessee MS Students 2 (Becky Stapleton) Select all the GO Teams on which you are currently a member. Teams are listed in alphabetical order by location.Parent/Guardian Name* First Last Relationship Contact Information Home Phone Cell Phone Email Prescription MedicationMedication #1 Medication Dosage What Time Reason For Taking Medication #2 Medication Dosage What Time Reason For Taking Medication #3 Medication Dosage What Time Reason For Taking Medication #4 Medication Dosage What Time Reason For Taking Consent for Administration of Prescription & Over the Counter MedicationsPlease indicate whether or not you would prefer for your student or an adult team leader to be responsible for both storing and administering any prescribed medications in the field by checking the appropriate box below. Note that for security reasons students must travel with their own prescription medications packed in their personal carry-on and if indicated below will give them to a team leader once they have reached their destination.* I would like my student to keep prescribed medication in his/her possession and administer themselves as directed I would like an adult leader on the team to be responsible for both keeping and administering my student’s prescribed medication in the field Over The Counter MedicationsThe following non-prescription medications will be carried by the GO Team Leader(s) and made available as needed to team members. Please check the boxes below to indicate all medications you consent to your child receiving in the recommended doses without requiring that you be contacted from the field.* Select All Advil OR generic Ibuprofen (NSAID) 200mg per tablet Benadryl Ultratab OR generic Diphenhydramine HCI 25mg per tablet Claritin 12 hour OR generic Loratadine 5 mg per tablet Colace Regular Strength OR generic Docusate Sodium 100mg per tablet Coritizone 10 Hydrocortisone 1% Dramamine Less Drowsy OR generic Meclizine HCI 25mg per tablet Imodium OR generic Loperamide HCI 2mg per caplet Neosporin OR generic Pepto-Bismol Chewables OR generic Bismuth subsalicylate 262mg per tablet Sudafed PE or generic Phenylephrine HCI 10mg per tablet Tums Extra Strength OR generic Calcium Carbonate 750mg per tablet Tylenol Cold Multi-Symptom OR generic Daytime - Acetaminophen 325 mg, Dextromethorphan HBr 10 mg, Phenylephrine HCI 5 mg) Tylenol Cold Multi-Symptom OR generic Nighttime - Acetaminophen 325 mg, Chlorpheniramine maleate 2 mg, Dextromethorphan HBr 10 mg, Phenylephrine HCI 5 mg) Tylenol Extra Strength or generic Acetaminophen 500mg per caplet I acknowledge that all the information provided on this form is accurate and complete and consent to my child receiving their prescription medication as indicated as well as the over the counter medications I have indicated on the previous page without requiring additional consent at the time of distribution.Today's Date*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Signature* Δ