Request For Administration Of Medication

Request For Administration Of Medication

The school's medication policy complies with state regulations. This form must be completed and signed by a physician or a licensed prescriber and/or parent/guardian and returned to the school office before any medication including over-the counter drugs can be administered at school. No medication of any kind is provided to students by the school even with a signed permit.
All medication must be in the original container with appropriate labeling and not expired. Prescription medications must, in addition, include the student’s name, name of physician, pharmacy phone number, and specific directions for administration.
Student's Name

First NameLast Name
Medication Name
Dose
When to Give
Reason for Medication
How long the medication is to be given (Ex. 10 days, 3 months, indefinitely)
STUDENTS MAY KEEP EMERGENCY MEDICATION (INHALERS, EPIPENS) WITH
THEM ONLY WITH THE SIGNED PERMISSION OF A PARENT AND THE ORDERING PHYSICIAN WHO AGREE THAT THE STUDENT IS TRAINED AND KNOWLEDGEABLE ABOUT HOW AND WHEN TO ADMINISTER IT TO HIM/HERSELF.
Physician's Signature

Clear
Date

MonthDayYear
Parental Authorization
I herby give me permission for First Name Last Name to take the above named mediation at school as ordered. I understand that it is my responsibility to furnish this medication. I also understand that any designated school employee who administers this medication to my child in accordance with written instructions from the prescribing health care provider and/or parent/guardian shall not be liable for damages as a result of an adverse drug reaction suffered by the pupil or because of a mislabeled or altered product.

I hereby authorize the exchange of information regarding this request with the above named physician and/or the pharmacy as identified on the affixed pharmacy label as necessary.
Parent/Guardian Signature

Clear
Date

MonthDayYear
Daytime Phone
Please enter a valid phone number.
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