Kenosha Unified School District No. 1 Medication Authorization Form printable pdf download

KENOSHA UNIFIED SCHOOL DISTRICT NO. 1

MEDICATION AUTHORIZATION FORM

SCHOOL NAME: _________________________________ PHONE: _____________ FAX: _____________

ONE MEDICATION PER FORM

Prescription Medication:

Health Care Provider to complete. Health Care Provider signature required.

Parent/Guardian signature required.

Non-Prescription Medication:

Parent/Guardian to complete. Parent/Guardian signature required.

Medication to be administered as directed.

Student Name: _____________________________________________________ DOB: ____/____/________

Medication: ______________________________________________________________________________

Dosage: _________________________________________________________________________________

Route: __________________________________________________________________________________

Time(s) Administered: ______________________________________________________________________

Reason for Medication: _____________________________________________________________________

Student may carry medication for Emergency purposes:

______ Yes

______ No

Additional directions/symptoms: ______________________________________________________________

Health Care Provider Signature: _______________________________________ Date: ____/____/________

Health Care Provider Name (Please Print): ______________________________________________________

Address: __________________________________________ Phone: _____________ Fax: _____________

NOTE: Parent/Guardian signature permits designated school staff to dispense medication to the above student

and to contact the health care provider at any time with questions or concerns related to this student’s medical

condition and medication.

Parent/Guardian Signature: ___________________________________________ Date: ____/____/________

Parent/Guardian Name (Please Print): _________________________________________________________

Daytime Phone Number: ____________________________________________________________________

CRITERIA FOR DISPENSING MEDICATION

1. Authorization: Students requiring medication at school, including herbal and vitamin supplements, shall

provide a completed “Medication Authorization Form”. Prescription medications require a signature from

both a health care provider and parent/guardian. Non-prescription medications require the

parent/guardian signature. The parents must notify the school when the drug is discontinued or for any

changes. An updated medication authorization form is required for all changes in medication, dosage, or

administration time. All medication authorization forms must be renewed annually. All unclaimed

medication at the end of the school year will be disposed of per policy.

2. Container: All medication must be supplied in the original container. Prescription medications require the

pharmacy label. Non-prescription medication must be in the original container with the directions on the

container including student name. All medication shall be kept in a locked cabinet.

3. Delivery to School: It is the responsibility of the parent/guardian to provide and deliver to the school all

authorized medication and replace expired medication.

Hedata\Clerical\Nursing\forms\kusd med authorization form 2011

01/17/2011

rcc

Kenosha Unified School District No. 1 Medication Authorization Form

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