Pmea Medication Administration Record Form
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1PMEA MEDICATION ADMINISTRATION RECORD
*A separate form is required for each medication, including asthma inhalers and epinephrine
auto-injectors which are carried by the student for EACH Fest/Festival and EACH advancement, if
applicable (i.e. district, region, state)
(Please PRINT/TYPE all information below, except signatures)
Student Name:
DOB:
/
/
Licensed Prescriber Name:
Licensed Prescriber Address:
Licensed Prescriber Phone #: (
)
Licensed Prescriber Signature:
Medication/Dose/Route/Time(s) to Administer:
I give permission for the fest/festival nurse to give the above medication to my student.
Signature Parent/Guardian
Date
Date/Time
CODES
Initials
Name
W: Dose Withheld (Chart
reason in student log)
*ALL medication must be administered by the fest/festival nurse, regardless of the student’s age or
Section 504 or Transition Plan.
Updated July/August 2016
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Parent category: Medical