Request For Medication To Be Taken During School Hours
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1
2Attachment A
33.199 Eng Rev. 9/07
LOS ANGELES UNIFIED SCHOOL DISTRICT
Student Health and Human Services
REQUEST FOR MEDICATION TO BE TAKEN DURING SCHOOL HOURS
(To be completed by a CA Licensed Health Care Provider)
Student name
Last
First
Sex
Birth date
School
Name of medication
Date of prescription
Dosage prescribed
Time schedule at school
Dose form
Route
(Tablet, liquid, injection, inhalant, etc.)
Purpose of medication or diagnosis
Licensed Health Care Provider’s Recommendations (Check where applicable)
The medication may have adverse side effects (explain)
Special instructions and/or comments
The student for whom this medication is prescribed is under my care.
Print name/Title
Signature
Date
(___)
Address
City
State
Zip code
Telephone
(
)
Print name of Supervising Physician
NP, Midwife, PA
Furnishing Number
(NP/Midwife)
-------------------------------------------------------------------------------------------------------------------------------
REQUEST FOR MEDICATION TO BE TAKEN DURING SCHOOL HOURS
(To be completed by parent/guardian)
I request that my child
, be assisted in using prescribed
medication at school. I assume full responsibility for supplying all medication and shall deliver it,
or have it delivered, to the school by another responsible adult, and agree to the District policies
and procedures listed on the reverse side. I give my permission for the exchange of medical
information regarding administration of medication at school with the authorized health care
provider and pharmacist.
____________________________
Date
Signature of Parent/Guardian/Student 18 years
Printed Name
(____)_________________
(____)_________________
(____)________________
Home telephone
Work telephone
Cellular telephone
BUL-3878.1
Student Health and Human Services
Page 1 of 2
September 24, 2007
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