SLIGO MIDDLE SCHOOL
8th Grade
End of Year Activities
Packet
Permission Slip for Eighth Grade Field Trip
Date: Wednesday, June 3, 2015
Destination: Doswell, Va.
Enduring Understanding: Kings Dominion gives students opportunities to gain better insight into how science,
technology, engineering, and mathematics work together to make really exciting and fun adventures in the
amusement park. Your child will also continue establishing and maintaining positive collaborative relationships
with their peers and continue opportunity to demonstrate the Sligo Rs.
Time Leaving School: 7:30 AM
Time Returning: 8:00 PM
Cost for Park admission and Buses: $95.00 (checks payable to Sligo MS or Money Order) The payment covers
the following:
 Bus Transportation
 Park Entry
 Class T-Shirt

Parents
please be advised that we encourage you to provide money so that your child can account for any
incidentals incurred inside of the park that include: snacks, beverages, souvenir shopping, or photo booth opportunities.
Please note that a school lunch will be provided, however students are welcome to bring a bag lunch.
Permission slip and payment to Sligo MS must be returned no later than Friday, May 15th. We expect that all
students will attend this trip. Please contact Ms. Tutt, Mr. Godoy, or guidance counselors if financial aid is
needed.
I give permission for my child, __________________________________, to go on the field trip described
above. In the event that MCPS is unable to reach me, I give permission for MCPS personnel to seek
appropriate medical care if needed. If medication has to be administered during the trip form 525-13
(Authorization to Administer Prescribed Medication) must be completed by your child’s doctor.
My child has the following medical condition: ___________________________________________________
Parent/Guardian Signature: _______________________________
Date: __________________
Emergency telephone numbers: _____________________________________________________________
**If you would like to participate on this trip as a volunteer the cost is $95.00**
I would like to be a volunteer on this field trip: ______YES
Phone Numbers: _________________________
______NO
Print Name: __________________________________
Email address: ____________________________________________________
Volunteers who are not employees of MCPS are not covered by the MCPS insurance unless an injury occurs on an MCPS vehicle and
the MCPS operator is negligent. Preschool aged children may not accompany parents when the parents serve as chaperones.
Students who hold the student accident policy available at the beginning of each school year or at the time of entry are covered on
an approved field trip within the liability limits of the policy as described in the insurance brochure.
__________________________________________(Student Name)
has my permission to attend the King’s Dominion end of the year field trip on Wednesday, June
3, 2015 from 7:30 a.m. to 8:30 p.m.
Please check all that apply:
o
o
o
o
o
I understand that my child/ren must arrive to school no later than 7:30 a.m.
I understand that I must pick my child/ren up by 8:30 p.m.
My child/ren has permission to go home with___________________.
We understand that MCPS school policies are to be followed at all times.
If your child/ren has allergies or other medical concerns, please contact Mrs. Tutt
directly.
o I have included a donation to the trip fund of $________.
o I am able to volunteer on this trip. I am aware that I would be financially
responsible for entrance fees/chartered bus accommodations of $95.00.
I understand the following will result in my child/ren being unable to attend the trip:
o Any suspension
o 3 or more Administrative Referrals
Emergency Contact:
Parent/Guardian Name: ___________________________________________________
Cell: ___________________________________ Work: ___________________________
Parent Signature_________________________________
Student Signature________________________________
MONTGOMERY COUNTY PUBLIC SCHOOLS
MONTGOMERY COUNTY DEPARTMENT of
Health and Human Services
Rockville, Maryland 20850
AUTHORIZATION TO ADMINISTER
PRESCRIBED MEDICATION
Release and Indemnification Agreement
PART I—TO BE COMPLETED BY THE PARENT/GUARDIAN
I hereby request and authorize Montgomery County Public Schools (MCPS) and Montgomery County Department of Health and Human
Services (MCDHHS) personnel to administer prescribed medication as directed by the physician (Part II below). I agree to release, indemnify,
and hold harmless MCPS and MCDHHS and any of their officers, staff members, or agents from lawsuit, claim, demand, or action against
them for administering prescribed medication to this student, provided MCPS and MCDHHS staff are following the physician’s order as
written in Part II below. I have read the procedures outlined on the back of this form and assume the responsibilities as required.
Student: Birthdate: Prescription: □ Renewal □ New
/
/
School: If new, the first full day's dosage was given at home on: /
/
List all medication(s) student is taking, including over-the-counter medication(s): Parent/Guardian Signature
-
-
Phone Number
/
Date
/
PART II—TO BE COMPLETED BY THE PHYSICIAN
The Montgomery County Department of Health and Human Services and the Montgomery County Public Schools discourage the
administration of medication to students in school during the school day. Any necessary medication that possibly can be administered
before and after school should be so prescribed. Only non-parenteral medications are administered except in specific emergency
situations. School personnel will, when it is absolutely necessary, administer medication to students during the school day and while
participating in outdoor education programs and overnight field trips, according to the procedures outlined on the back of this form.
PLEASE USE A SEPARATE FORM FOR EACH MEDICATION
Name of Medication: Trade name and/or generic
Dosage: Ranges not accepted (i.e. 1 to 2 tabs or 2 to 4 puffs)
Diagnosis: Time(s) To Be Given At School: Route of Administration: Effective Dates: From /
/
To /
/
Side Effects: If PRN, specify:
When indicated (signs/symptoms) Frequency of administration Ranges not accepted (i.e. every 2 to 4 hours)
Physician’s Name (print/type)
Physician Signature -
-
Phone Number
/
Date
/
SELF-CARRY/SELF-ADMINISTRATION OF EMERGENCY MEDICATION AUTHORIZATION/APPROVAL
Self-carry/self-administration of emergency medication such as inhalers and EpiPens® must be authorized by the prescriber and
be approved by the school nurse according to the State medication policy:
Prescriber’s authorization for self-carry/self-administration of emergency medication
/
/
Signature
School Registered Nurse (RN) approval for self-carry/self-administration of emergency medication
Date
/
/
SignatureDate
PART III—TO BE COMPLETED BY THE PRINCIPAL OR SCHOOL NURSE
Check as appropriate:
Parts I and II above are completed, including signatures. (It is acceptable if all items of information in Part II are written on the
physician’s stationery/prescription blank.)
Prescription medication is properly labeled by a pharmacist.
Medication label and physician order are consistent.
Over-the-counter
medication is in an original container with the manufacturer’s dosage label and safety seal intact.
/
/
Date any unused medication is to be collected by the parent or guardian (within one week after expiration of the
physician’s order).
Principal/School Nurse Signature
MCPS Form 525-13, Rev. 1/13
/
Date
/
DISTRIBUTION: COPY 1/Student Health Record; COPY 2/Parent/Guardian
INFORMATION AND PROCEDURES
1. No medication will be administered in school or during school-sponsored activities without the parent’s/
guardian’s written authorization and a written physician order. This includes both prescription and overthe-counter (OTC) medications.
2. The parent/guardian is responsible for completing Part I and obtaining the physician’s statement on Part
II. This is required every school year for each new or continuing order or if there is a change in dosage or
time of administration during the school year. (A physician may use office stationery or prescription pad
in lieu of completing Part II.) Information necessary includes: child’s name, diagnosis, medication name,
dosage, time of administration, duration of medication, side effects, physician signature, and date.
3. The medication must be delivered to the school by the parent/guardian or, under special circumstances, an
adult designated by the parent/guardian. Under no circumstances will either the school health (MCDHHS)
or school (MCPS) personnel administer medication brought to school by the student.
4. All prescription medication must be provided in a container with the pharmacist’s label attached. Nonprescription OTC medication must be in the container with the manufacturer’s original label. Physician
samples must be appropriately labeled by the physician.
5. The first day’s dosage of any new medication must have been given at home before it can be administered
at school.
6. The parent/guardian is responsible for collecting any unused portion of a medication within one week after
expiration of the physician’s order or at the end of the school year. Medication not claimed within that
time period will be destroyed.
7. Self-administered and/or non-medically prescribed medications are entirely the responsibility of the parent/
guardian and not that of either the Montgomery County Public Schools or Montgomery County Department
of Health and Human Services. Medications without accompanying physician’s orders and parental consent
will not be stored in the health room.
8. Students may not self-administer controlled substances.
9. A physician’s order and parental permission are necessary for self-carry/self-administered emergency
medications such as inhalers for asthma and EpiPens for anaphylaxis. The school nurse must evaluate
and approve the student’s ability and capability to self-administer medication. It is imperative the
student understands the necessity for reporting to either the health staff or MCPS staff that they have
self-administered their inhaler without any improvement or have self-administered an EpiPen, so
911 may be called.
10.The school registered nurse (RN) will call the prescriber, as allowed by Health Insurance Portability and
Accountability Act (HIPAA), if a question arises about the child and/or the child’s medication.
8th Grade Dinner Dance
Friday, June 5, 2015
7p.m. - 9p.m.
Sligo Middle School’s
Cafeteria
Semi-Formal
Attire
Enjoy an evening of
delicious, catered food, DJ,
dancing, & photobooth.
*Submit the permission form to Mrs. Taylor-Rubin, at the time of purchase.*
PLEASE COMPLETE PERMISSION SLIP AND RETURN IT BY MAY 27, 2015
____________________________
First Name
_______________________________ has my permission to attend the Grade 8
Last Name
Dinner & Dance on Friday, June 5, 2015. I have discussed the Sligo Middle School’s Discipline Policy with my child.
Semi-Formal Attire will be worn: NO JEANS.
I have made arrangements to pick-up my child when the dance is over at 9:00 PM.
______ The $15.00 ticket payment is attached.
DONATIONS ACCEPTED $________
Printed Parent/Guardian Name: ___________________________________________________________________
PARENT/GUARDIAN SIGNATURE: _____________________________________________________________
HOME PHONE:_______________________________ CELL PHONE:_______________________________
STUDENTS: I HAVE READ AND UNDERSTAND THE EXPECTATIONS. I WILL MEET THEM.
STUDENT SIGNATURE: __________________________________________DATE:___________________
Promotional Exercise
Location: Northwood High School
When: June 12th @ 7:00 pm
Please Note:
Correspondence framing our promotional exercise and ticket dissemination will be available the
last week of May.