The Stonehaven School Medication Administration Form printable pdf download

The Stonehaven School

Medication Administration Form

Student’s Name: __________________________________________________________________

Teacher: _________________________________________ Grade: _________________________

I request that The Stonehaven School, through the principal or designee, supervise/assist

in the administering of medication to my child according to the instructions below. I understand that:



Medications must be in the original labeled container (no baggies foil, etc.) Pharmacies can provide

a duplicate labeled container with only the school doses.



Parent/guardian must provide special instructions, as well as the medication and related equipment

to the principal or school personnel.



It will be the responsibility of the parent/guardian to inform the school of any changes. New

medications or new doses will not be given unless a new form is completed and a newly labeled

container is provided.



All medications will be taken directly to the office by the parent/guardian.



Unused medication will be disposed of unless picked up within one week after medication is

discontinued.

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Name of medication: ______________________________________________________________

Dose: _________________________________ Route (by mouth, topical, etc.): _____________

Time(s) to be given: _____________________ Stop medication on: _______________________

Physician’s Name: _______________________ Physician’s Phone: ________________________

I hereby authorize the school personnel, employees and officials of The Stonehaven School to assist my child in taking

prescribed medication according to school policy and I release them from any liability for administering this medication. I

understand that, in the event of a change in medicine, I am responsible for presenting a new request form.

________________________________________________

_______________________________

Parent/Legal Guardian

Date

Home Phone __________________ Work Phone ___________________ Cell Phone ____________________________

To be completed by healthcare provider for prescription medications given for more than two weeks.

Condition/Illness Requiring Medication: _________________________________________________

Possible Side Effects if any:_____________________________________________________________

_______________________________________________

_________________________________

Signature of Healthcare Provider

Date

The Stonehaven School • 505 Atlanta St SE • Marietta, GA 30060 • (770) 874-8885

The Stonehaven School Medication Administration Form