•                                                 SCHOOL MEDICATION PRESCRIBER/PARENT AUTHORIZATION

     

    STUDENT INFORMATION

     

    Student’s Name __________________________________________________Date of Birth______________________________

     

    School ________________________________  Grade __________  Teacher _________________________ School Year ______

     

    List any known drug allergies/reactions __________________________________Height (inches)_ ______ Weight (lbs) _______

     

     

    PRESCRIBER AUTHORIZATION

     

    Name of Medication _____________________________________ Reason for Taking __________________________________

     

    Dosage _______________ Route ________________________ Frequency/Time(s) to be given ____________________________

     

    Begin Medication __________________________________ Stop Medication _________________________________________

                                     Date                                                                                                      Date

     

    Special Instructions:

    Does medication require refrigeration?   Yes □   No  □

    Is the medication a controlled substance?   Yes □   No  □

    Is self-medication permitted and recommended for this student?   Yes □   No  □

    If yes, do you recommend this medication be kept “on person” by the student?   Yes □   No  □

     

    Potential Side Effects/Contradictions/Adverse Reactions __________________________________________________________

     

    Treatment Order in the event of an adverse reaction: _____________________________________________________________

    (Attach additional sheet or use the back of this form if necessary)

     

    I hereby affirm that this student has been instructed in the proper self-administration of the prescribed medication (s).

     

    ________________________________________   __________________   _____________________  ____________________

    Signature of Prescriber   (please print)                             Date                                     Phone                                       Fax

     

    PARENT AUTHORIZATION

     

    I authorize the School Nurse, the registered nurse (RN) or licensed practical nurse (LPN) to delegate to unlicensed school personnel the task of assisting my child in taking the above medication.  I understand that additional parent/prescriber signed statements will be necessary if the dosage of medication is changed.  I also authorize the School Nurse to talk with the prescriber or pharmacist should a question come up about the medication.

     

    Medication must be registered with the principal, his/her designee, or the school nurse.  It must be in the original, unopened, sealed container and be properly labeled with the student’s name, prescriber’s name, date of prescription, name of medication, dosage, strength, time interval, route of administration and the date of drug expiration when appropriate.

     

    ________________________________________   __________________   _____________________   ____________________

    Signature of Parent                                                            Date                                     Phone                                         Cell

     

     

    SELF-ADMINISTRATION AUTHORIZATION

     

    I authorize and recommend self-medication by my child for the above medication.  I also affirm that he/she has been instructed in the proper self-administration of the prescribed medication by his/her attending physician.  I shall indemnify and hold harmless the school, the agents of the school, and the local board of education against any claims that may arise relating to my child’s self-administration of prescribed medication(s).

     

    ________________________________________   __________________   _____________________  ____________________

    Signature of Parent                                                            Date                                     Phone                                        Cell