Request To Administer Medicine Form

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LEANDER INDEPENDENT SCHOOL DISTRICT
REQUEST TO ADMINISTER MEDICATIONS
REQUEST TO ADMINISTER MEDICATION
I request that designated personnel of Leander ISD administer the medication listed below to my child according to the label and/or
physician instructions. I agree to furnish an adequate amount of medication in the original container. I understand that Leander ISD
personnel will protect my child and not administer medication if this form is not completed or the medication is not furnished as required.
Please note: Non-Prescription/Prescription Medication cannot be sent home with the Student
At the end of the school year (circle one):
Dispose of medication
Parent will pick up
********Note: All remaining medications will be disposed of on the last day of school********
See back for more detailed information. Call your campus clinic at
for any questions.
Completed requests can be faxed to ___________________________________________
_.
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Prescription Medication
Name of Student: ____________________________________DOB: __________ Age: ______ Grade: _____ Teacher: ______________________
Name of Medication: _____________________________________ Exp. Date: _____________ Dosage: __________________________________
Condition for which the medication is prescribed: _______________________________________________________________________________
Time(s) to be given at school: __________________________________ Do not administer after the following date: _________________________
Side effects: ___________________________________________________________________________________________________________
Physician’s printed name: ____________________________________ Physician’s Signature: __________________________________________
Physician’s Telephone: ___________________________ Physician’s Fax: _____________________________ Date: _______________________
I give permission to my child’s school to administer the prescribed medication in accordance with the physician’s instructions above. I also give permission for the school to
contact the above health care provider about the administration of this medication. I understand that the School District, the Board and its employees shall be immune from civil
liability due to allergic reaction or other injuries resulting from the administration of medication to a student, provided such administration conforms to the requirements of this
policy.
Parent/Guardian Printed Name: __________________________________ Parent/Guardian Signature: ____________________________________
Home: __________________________________ Work: __________________________________ Cell: __________________________________
Email address: _______________________________________________________ Date: _____________________________________________
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Non-Prescription Medication
Name of Student: ________________________________________DOB: __________ Age: ______ Grade: _______ Teacher: ________________
Name of Medication: _____________________________________ Exp. Date: ______________ Dosage:_________________________________
Time(s) to be given at school: ___________________________________ Do not administer after the following date: ________________________
I understand that the School District, the Board and its employees shall be immune from civil liability due to allergic reaction or other injuries resulting from the administration of
medication to a student, provided such administration conforms to the requirements of this policy.
Parent/Guardian Printed Name:___________________________________ Parent/Guardian Signature: __________________________________
Home: __________________________________ Work: _________________________________ Cell: __________________________________
Email address: _______________________________________________________ Date: ____________________________________________

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