Medication Agreement Template
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1
2MEDICATION AGREEMENT
Department of Health Services
Student Name:_________________________________
Student Number:_________________________________
School:_______________________________________
Grade/Teacher:__________________________________
TO BE COMPLETED BY PARENT OR GUARDIAN
I hereby request and give my permission to the Jefferson County School District to administer medication to my child. I understand
that it is my responsibility to provide the medication in the original pharmacy/or physician labeled container that has the correct
medication dosage identified for my student. I also understand the school may not alter or change any medications from their
original form (cut or half pills, etc.)
Any prescription changes will require an additional signed and completed Medication Agreement.
Name of Student:_______________________________
Date of Birth:____________________________________
Medicaid?
No
Yes
Medicaid Number:_________________________________________________
Parent/Guardian Name:__________________________
Home/Work Phone:_______________________________
Name of Medication:____________________________
Dosage:_________________
Time:______________
Start Date:______________________
End Date:______________________
Route:_________________________
I give my permission for the school staff to contact the prescribing physician regarding this medication.
Signature of Parent/Guardian
Date
TO BE COMPLETED BY PHYSICIAN (FOR PRESCRIPTION)
Patient's Name:________________________________
Date of Birth:____________________________________
Medication:____________________________________
Purpose:_______________________________________
Dosage:_______________
Time(s) to be given at school:_______________________________________________
Start Date:______________________
End Date:______________________
Route:_________________________
Name of Physician:________________________
Office Phone Number:____________
Fax__________________
Signature of Physician
Date
Only school employees who are trained and delegated by the District Registered Nurse Consultant may administer medication. The
employee administering the medication must document the time they gave the medication in the appropriate box and then initial in
the appropriate box.
Name of District Registered Nurse Consultant who trained and delegated:_____________________________________
Initials
Person Dispensing Medication
Title
Date Delegated
Jeffco Department of Health Services/Medication
5/2009 HE924
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Parent category: Medical