Request For Medication To Be Given During School Hours Form printable pdf download

REQUEST FOR MEDICATION TO BE GIVEN DURING SCHOOL HOURS

PARENT REQUEST FOR MEDICATION ADMINISTRATION AT SCHOOL/PHYSICIAN’S ORDER

FORM 1

(page1)

This form should be used only when school personnel will be administering medication to your child.

If your child will be possessing and self-administering his/her medication, please request Form 2.

Child’s Name: __________________________________

DOB: _____

School: _________________________

Dear Parent/Guardian:

In order to help protect your child’s health, your consent and written authorization from a doctor are required when it is

necessary for your child to be administered either prescription or non-prescription medicines in the Durham Public

Schools. No medications will be administered to your child at school until this authorization has been received. A

separate form is required for each medicine. New authorization forms are required every year at the beginning of school,

whenever the dose or directions change, or when a new medicine is prescribed. Each medicine must be in an

appropriately labeled original container from the pharmacy or healthcare provider’s office. Most pharmacies will provide

an extra container for school use upon request. Administration of nonprescription medicines at school is discouraged.

I, _________________________________, understand that:



It is my responsibility to purchase and supply all medicines to be given at school.



The Durham Public Schools Board of Education and its employees and agents authorized to administer drugs or

medication prescribed by a doctor upon my written request shall not be liable in civil damages for any

administration or for any omission relating to the administration, unless that act or omission amounts to gross

negligence, wanton conduct, or intentional wrongdoing.



Information shared may be in the form of an emergency or individual care plan for my child and may include

information provided by my child’s physician, myself, or from records that have been released to the school from

another agency.



Exchange of information will be limited to the minimum necessary to provide the required assistance for my child

and will be shared only with those staff who may need to provide the specified assistance for him/her.



This consent to release information must be signed before my child’s teachers can provide assistance with

special medical needs other than notifying parents and providing Emergency Services (911).



If my child participates in DPS before/after-school activities/sports, I will assume responsibility for notifying the

advisor/coach of my child’s medical condition. Since the medication kept by the school is only available during

regular school hours, I will provide extra emergency medication that may be needed during the activity. I may

contact the school nurse if assistance is needed in instructing the advisor in a medical procedure or if a copy of

the information needs to be shared with them.

I, ____________________________, authorize the release and exchange of medical information between my child’s

physician, school nurse and Durham Public Schools that is necessary in carrying out services for my child, ___________

_________________________________. I, ____________________________, also hereby give permission for my child

_____________________________ to be administered the specified medication indicated by his/her physician on the

reverse. I understand that non-medical personnel conduct the administration. If an emergency injection is ordered, I give

permission for the School Based Public Health Nurse to instruct designated staff in the administration technique. I

understand that it is my responsibility to transport the medication to school unless special arrangements are made with

the principal.

____________________________________

___________________

Parent/Guardian Signature

Contact Information (home/work/cell)

Date

To be completed by school:

Date Received from Parent/Guardian: ____________________________________________

PLEASE IDENTIFY BELOW THE NAMES OF ALL DPS EMPLOYEES DESIGNATED and TRAINED TO ADMINISTER

MEDICATION TO STUDENTS IN YOUR SCHOOL.

Name ___________________

Title _________________ Name __________________________ Title ____________

Name ___________________

Title _________________ Name __________________________ Title ____________

Name ___________________

Title _________________ Name __________________________ Title ____________

Signature of Principal

_________________________________________________________ Date _______________

Request For Medication To Be Given During School Hours Form

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