Pikes Peak Regional Student Medication Form - Digital High School
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1COLORADO SPRINGS SCHOOL DISTRICT 11
Pikes Peak Regional Student Medication Form
Parents are encouraged to administer medication to their children outside of school hours if at all possible. Only
medications which are required to enable a student to stay in school may be given at school. If necessary,
medications (prescription, over the counter, homeopathic and herbal) can be given at school under the following
conditions:
1. All medications must be ordered by healthcare providers with prescriptive authority in Colorado
(MD, DO, Nurse Practitioner, Physician Assistant).
2. All medication forms must be renewed each school year.
3. Written permission by parent and physician in all cases.
4. Medications must be in the original, properly labeled container. Medications sent in baggies or unlabeled
containers will not be given.
5. All medications must be kept in the health room, except for students whose doctor requires them to carry
medications on their person (for example, epipen, inhalers, etc).
√ The information/form below must be completed and signed by the physician.
√ In addition, the medication bottle must match the prescription as written below.
STUDENT NAME:_____________________________
__________________________
First Name
Last Name
SCHOOL: ________________________________GRADE_________DOB____________
MEDICATION:______________________________DOSAGE:_______________________
TIME TO BE GIVEN: _________________________ROUTE:________________________
If PRN (as needed), please note the minimum duration time between doses (for inhalers, minimum time
frequency, frequency between sets of inhalation):_____________________________________________
Anticipated time frame: (Must be renewed each school year)
School Year:_____________ OR Specific Time Frame: FROM_________ TO___________
If medication is an inhaler or epipen, is the student given permission to carry on his/her person?
Physician, NP or PA’s Initials: (Physician / NP / PA MUST Initial)_______________
YES_____
NO______
Is a second dose allowed if there is an allergic reaction? YES _____
NO _____
Physician/NP/PA
Physician/NP/PA
Date:_________ Signature_______________________________________
Phone Number______________
Printed Name / Signature
PARENT / LEGAL GUARDIAN: To be completed by the student’s parent or legal guardian
REQUEST AND AUTHORIZATION TO ADMINISTER MEDICATION: I, ______________________________________ the parent or
legal guardian of ___________________________________, request and authorize that the medication identified above be
administered to my student by school personnel as prescribed by her/his physician in the manners specified above. I understand that it
is my responsibility to furnish the medication to the school in a properly labeled container.
RELEASE FROM LIABIITY: Further, I , for myself and my heirs, survivors, agents, child, immediate family and personal
representatives, hereby fully release and forever discharge the School District, its directors, officers, employees, agents,
representatives, attorneys, and successors and assigns, from any and all demands, claims, obligations, actions, liabilities, or damages
of any kind or nature whatsoever, in law or in equity, whether known or unknown, suspected, now or hereafter arising, which related in
any way to the administration of the medication provided by me.
Date:______________________________
________________________________________________
(Signature of Parent or Legal Guardian)
Form # 88324
25 pkg.
03/09
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