Medication Administration Form - Archbishop John Carroll High School

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A
J
C
H
S
RCHBISHOP
OHN
ARROLL
IGH
CHOOL
211 M
F
R
H
O
ATSON
ORD
OAD
EALTH
FFICE
R
PA 19087-4590
ADNOR
MEDICATION ADMINISTRATION FORM
RETURN TO SCHOOL HEALTH OFFICE
Request from parents to have medication administered in school
Date:
__________________________________
Name of Student:
_________________________________________________
Medication:
________________________________________________________
Dosage:
________________________________________________________
Time: __________________________________
Directions for Administration: ______________________________________________________
______________________________________________________
Comments:
_________________________________________
________________________________________
Parent/Guardian Signature
Physician Signature
________________________________________
Phone Number
Prescription medications will not be administered in school without specific orders from a physician. This
form must be completed by the physician ordering the medication and must accompany the prescription and
kept on file in the Health Office for the current school year. Medication provided must be in the original
prescription container which includes the following legible information on the label:
Individual pupil’s name
Date prescription filled
Medication
Time and dosage to be given
Name of prescribing physician
The medication will not be given in school if the date on the prescription container is over one year old.
Remaining medications not consumed by the end of the school year should be picked up before the last day
of school, otherwise it will be destroyed in the presence of a school administrator.
Please notify the School Nurse if there is any change in your child’s prescribed medication, or if you have
any questions or concerns.

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