ALPHA KAPPA ALPHA SORORITY, INCORPORATED

Rho Mu Omega Chapter and DC Pearls III Foundation, Inc. 

2019

                  Historically Black Colleges and Universities (HBCU)                         Middle School Tour Application

STUDENT INFORMATION

Personal Information

MEDICAL INFORMATION

Prescription and over-the-counter medication

List the full names of all of the prescription and over-the-counter medications currently being taken by your child. Copy the information from the containers when completing the charts below.
 Name of MedicationDosageFrequency TakenReason for Taking
1.
2.

Allergies

List the names of any medications and food allergies your child may have. Please include the type of allergic reaction your child will experience.
 Name of MedicationReactionFoodReaction
1
2
3
4

Students should be in possession of only the medication listed on this form while on the tour. All medications must be in original bottles/containers.  Chaperones will not be responsible for administering any medication.