Seizure Disorder Health Care Plan And Medication Administration Authorization Form (Page 3 of 3) in pdf

Page 3 of 3

PRINCE GEORGE COUNTY PUBLIC SCHOOLS

Seizure Disorder Health Care Plan and Medication Administration Authorization

I, ____________________________________________, parent or legal guardian of __________________________________,

request that the principal’s designee at ___________________________________ School administer the prescribed medication

and provide care to my child as indicated on the Seizure Disorder Health Care Plan dated ______________________________.

I give the principal’s designee permission to contact the licensed prescriber if necessary. In signing this form, I am agreeing to

hold the school and its personnel free from any legal action that might arise from this arrangement.

I also understand that I am to abide by the school division regulations as stated below:

It is my child’s responsibility to come to the clinic to take his/her medication.

•

Parent or guardian must bring medication into school office or clinic. Medication cannot be transported on buses or by

•

students.

The first dose of a new medication should be given at home.

•

Prescription medication must have a current prescription label that corresponds with the written authorization.

•

Any changes in a medication require a new written authorization and corresponding change in the prescription label.

•

Parent or guardian must provide medications/equipment required to administer medications or provide special medical care.

•

Left over medication must be picked up at the end of the school year or it will be discarded.

•

I approve this Seizure Disorder Health Care Plan for my child. I give permission to share information about my child’s seizure

disorder with the school nurse, teachers, principals, office staff, guidance, bus driver/transportation and cafeteria manager as

appropriate. I give the principal or his designee the authority to call the rescue squad or take my child to a hospital emergency room in

case of emergency.

Parent/Guardian Signature _______________________________________________

__ Date ______________________

Parent/Guardian PRINTED Name _____________________________________

_________________________________

Home Phone ________

Work Phone _____________________ Cell Phone _____________________

______________

School Use:

Health care plan information provided by __________________________________________ to the following staff:

Names of Persons and Date

_______________________________________________

Staff members trained to administer medication and assist with this student’s care at school in the absence of the nurse:

Name of Person

Location or Room Number

Date Trained

______________________________________________________________________________________________________

HSM 0005-0809

Seizure Disorder Health Care Plan And Medication Administration Authorization Form Page 3

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