PARENTAL AUTHORIZATION FOR RX/OTC MEDICATION ADMINISTRATION

STUDENT INFORMATION:

Date: ______

Student’s Name: ______Age: ______Sex: ______

DOB: ______Grade: ______

MEDICATION / PRESCRIPTION INFORMATION:

Please Note: All medications,Doctor prescribed (RX) and Over-the-Counter(OTC), must be brought to the HealthOffice by the parent/guardian of student(s) receiving medication. Parent may also designate a responsible adult to bring medication to the Health Office for said student(s) or area pharmacies will deliver to school.

[ ] Prescription Medication [ ] Over-the-Counter Medication provided by Parent/Guardian

(current date on bottle) (unopened container)

Medication Name: ______Mg: ______

Physician: ______Phone: ______Fax: ______

Pharmacy: ______Rx # ______Rx Filled: ___/___/___

Amount Sent: ______(in new unopened container)

Reason for Medication: ______

Dosage: ______Route: ______

[ ] Tablets/Capsule [ ] Liquid [ ] Inhaler [ ] Injection [ ] Nebulizer [ ] Other ______

Medication to be given: Time ____:____ AM / PM [ ] As needed [ ] With lunch ______

Start Date: ____/____/____ Discontinue Date: ____/____/____

Special Medication Storage Requirements: [ ] None [ ] Refrigerate [ ] Other ______

Has the student been given the first dose of this medication? [ ] Yes [ ] No

Are there restrictions and/or important side effects? [ ] Yes [ ] No

If yes, please describe: ______

______

______

"PLEASE COMPLETE "BOTH" SIDES OF THIS FORM”

PHYSICIAN INFORMATION:

Physician: ______

Address: ______

Phone #:______Fax #: ______

***************

I give permission for <First Name> <Middle Name> <Last Name> to receive the medication(s)

listed on front of this page, at school.

Please indicate any additional information: ______

______

______

  • I understand I may cancel this request at any time, and / or retrieve the medication from the school

at any time. I understand the medication will be destroyed if it is not picked up within one week following termination on this order or beyond the close of the school year.

  • I understand that any school employee who administers above medication to my child, in accordance

with these instructions, shall not be liable for damages as a result of an adverse drug reaction by the

student because of administering such drug.

  • I give district employees permission to contact the student’s physician directly for the exchange of

verbal and written communication between the physician and the school nurse / health assistant

regarding my child’s medication regime and information on the student’s condition. I understand that

I have the ultimate responsibility for providing the school with an adequate supply of medication and

for informing the school district immediately if any information provided on this form changes or if administration of medication should cease.

Please Note: All medications,Doctor prescribed (RX) and Over-the-Counter (OTC), must be brought to the Health

Office by the parent/guardian of student(s) receiving medication. Parent may also designate a responsible adult

to bring medication to the Health Office for said student(s).

_____ (Initials needed) I have read all the information above and agree to bring medication(s) to school for said student(s), myself or send with a responsible adult if said student(s) need medication throughout the current school year.

xSignature of Parent/Guardian______Date: ___/___/___

Relationship: ______

Home Phone: ______Work Phone: ______Emergency Phone: ______

NOTICE:

Schools in this district are equipped with epinephrine pre-measured auto-injection devices that can be administered in the event

of severe allergic reactions that cause anaphylaxis. Epinephrine will be administered only in accordance with written protocols provided by the authorized prescriber. The school principal will maintain a list of personnel trained in the proper administration

of this drug.

Updated 03/2013