Request For Medication Administration
ADVERTISEMENT
1PENDER COUNTY SCHOOLS
Request for Medication Administration in School
To be completed by physician
Name of Student:_______________________________________________ School:____________________________
Medication:______________________________________________ Dosage:_________________________________
Time(s) medication is to be given at school: a.m._________ p.m.__________
Date to be given from: _________________ to__________________
Significant Information (include side effects, toxic reactions, omission reactions):______________________________
_______________________________________________________________________________________________
Contraindications for Administration:_________________________________________________________________
_______________________________________________________________________________________________
If an emergency situation occurs during the school day or if the student becomes ill, school officials are to:
a.
Contact me at my office__________________________ Telephone__________________________
b.
Take child immediately to the emergency room at________________________________________
FOR SELF-ADMINISTRATION -
Student has demonstrated understanding of and ability to self-administer asthma medication, diabetes
medication, or medicine for anaphylactic reactions and may carry and self-administer as prescribed.
[Asthma/allergic reaction MDI (*Medicated Dose inhaler) MDI with spacer * Epinephrine auto-injector
diabetes –insulin] *Parent/guardian must provide an extra inhaler to be kept at school in case of emergency
A written statement, treatment plan and written emergency protocol developed by the student’s health care provider
must accompany this authorization form in accordance with requirements stated in G.S. 115C –375.2
Student must have a self-medication treatment agreement/contract.
All prescription medication for use at school will be furnished by parent or guardian in a container properly labeled by a
pharmacist and over the counter medicine must be in the original container. All medicines must have identifying
information, (e.g., name of child, medication dispensed, dosage prescribed, and the time it is to be given or taken).
___________________________________ __________________________________ ________________________
Physician’s Signature
(Print Physician Name)
Date
PARENT’S PERMISSION
I hereby give my permission for my child (named above) to receive medication during school hours. This medication
has been prescribed by a licensed physician. I hereby release the School Board and their agents and employees from all
liability that may result from my child taking the prescribed medication. This consent is good for the school year,
unless revoked.
_________________________________ ______________________________________________ ____________
Parent or Guardian’s Signature
Telephone Number(s)
Date
(School Use Only)
Approved by__________________________________________________ _________________________________
Principal’s Signature
Date
Reviewed by _________________________________________________ _________________________________
School Nurse’s Signature
Date
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Education