Medication Administration Form - Hillsdale Local Schools (Page 2 of 2) in pdf

Medication Administration Form - Hillsdale Local Schools Page 2

HILLSDALE ELEMENTARY SCHOOL

PHYSICIANS REQUEST

FOR THE ADMINISTRATION OF MEDICATION BY SCHOOL PERSONNEL

____________________________ is under my care for (purpose of Medication)

Name of Student

______________________, and should receive __________________________

Name of Drug, Dosage, Route

at the following times _______________________________________________

Specific instructions for administration __________________________________

Possible side effects to watch for ______________________________________

Expiration date of this request ________________________________________

Date ____________

_____________________________________

Physician’s Signature

_____________________________________

Physician’s Phone Number

PARENTS REQUEST

FOR THE ADMINISTRATION OF MEDICATION BY SCHOOL PERSONNEL

I hereby request and give my permission to the principal or his delegate (school nurse

or other responsible person) to administer the following medication to my child.

Furthermore, I/We understand that it is my/our responsibility: (1) to deliver the

medication to the school; (2) that prescribed medicines shall be stored in the original,

labeled container; (3) to notify the school in writing of any change in medication.

Name of Child ____________________________________________________

Name of Drug __________________ Dosage____________Route___________

at the following time(s) ______________________________________________

No employee who is authorized by the Board of Education to administer a prescribed

drug and who has a copy of the most recent physician’s statement, will be liable for civil

damage arising from the administering or failing to administer the drug, unless the

employee acted in a manner that would constitute negligence or misconduct.

Date ________________ __________________________________________

Signature of Parent or Guardian

Medication Administration Form - Hillsdale Local Schools Page 2