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MEDICATION ADMINISTRATION FORM
Student's Name
*
Date
*
-
Month
-
Day
Year
Date
School
Grade
Teacher
Is the student in Resource or Special Ed?
Yes
No
Does the student ride the bus?
Yes
No
Bus #
Parent/Guardian
Phone Number
Please enter a valid phone number.
Address
Emergency Contact
Emergency Contact Phone Number
Please enter a valid phone number.
Doctor's Name
Doctor's Phone Number
Please enter a valid phone number.
Doctor's Fax Number
Please enter a valid phone number.
Medical Diagnosis
*
ie. ADHD, Asthma, Allergies, Diabetes...
Name of Medication #1
*
Dosage #1
*
ie. 25mg, 2 tsp...
Route #1
*
ie. by mouth, subcutaneous, in the ear...
Time #1
*
ie. at 11am, before exercise, as needed...
Add another medication?
Yes
No
Name of Medication #2
*
Dosage #2
*
ie. 25mg, 2 tsp...
Route #2
*
ie. by mouth, subcutaneous, in the ear...
Time #2
*
ie. at 11am, before exercise, as needed...
Add another medication?
Yes
No
Name of Medication #3
*
Dosage #3
*
ie. 25mg, 2 tsp...
Route #3
*
ie. by mouth, subcutaneous, in the ear...
Time #3
*
ie. at 11am, before exercise, as needed...
Add another medication?
Yes
No
Name of Medication #4
*
Dosage #4
*
ie. 25mg, 2 tsp...
Route #4
*
ie. by mouth, subcutaneous, in the ear...
Time #4
*
ie. at 11am, before exercise, as needed...
Choose One:
*
Student will carry/self administer medication
School staff will store and administer medication
No Medication required
Medication and/or medical supplies will be located at:
*
Office
Student's desk
Locker
Teacher's desk
Student's backpack
Other
I approve of my patient's/child's healthcare plan and prescribed medications as stated above.
Signature of Parent/Guardian
*
Clear
Date
-
Month
-
Day
Year
Date
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