Student Self Medication Administration Form printable pdf download

Student Self Medication Administration Form

PHYSICIAN ORDER AND PARENT/GUARDIAN AUTHORIZATION FOR SELF MEDICATION ADMINISTRATION

(Please complete one form for each medication.)

Student’s Name: _____________________________________________________________ DOB: _______________________

Allergies: _______________________________________________________________________________________________

Medication: _______________________________________ Dosage: ______________________ Route: __________________

Reason for medication or diagnosis: _________________________________________________________________________

School Year: __________

Self-administration of medication by student

Only emergent/urgent medication will be considered for self-administration by a student. The student will be evaluated on an

individual basis regarding the need to carry emergency medication. This Student Self Medication Administration form is required

and must be signed by the student’s physician/healthcare provider and parent verifying the necessity and student’s ability to self

administer the medication appropriately. Please be sure to complete ALL of the information on this authorization form before

returning it to school. This authorization is valid for one school year and must be renewed at the beginning of each new school year.

PHYSICIAN’S ORDER

1. I have examined this student for (diagnosis): _______________________________________________________ and have

determined that he/she requires access to personal emergency medication during school hours.

2. Name of Medication _______________________________

3. Dosage & Route: _________________________

4. I believe this student is able to carry and administer his or her own medication (excluding controlled substances) at the

appropriate time and in the appropriate way.

Please check: ____YES _____ NO *I understand that self-administered medication is not provided by or monitored by the school

staff.

Physician’s Signature: _____________________________________ Date: _____ / _____ / _____

Printed Name: ____________________________________________ Phone: _____________________

PARENT/GUARDIAN STATEMENT

I, the undersigned Parent(s) Guardian(s) of ______________________________________ give consent for my student to self-

administer the above medication. I hereby agree to release and hold the school staff free and harmless for any claims, demands, or

suits for damages from any injury or complication that may result from such treatment. I have read this consent and understand all

its terms. I sign it voluntarily and with full knowledge of its significance. I understand that self-administered medication is not

provided by or monitored by the KORE office and school staff. * Parent / Student are responsible to have the medication available

at school.

X _______________________________________________________

____ / ____ / ____

(Parent/Guardian Signature)

Date

Home Phone: ____________________________Work: _______________________Cell: __________________________

Student Self Medication Administration Form