School Medication Authorization Form printable pdf download

KILDEER COUNTRYSIDE COMMUNITY CONSOLIDATED SCHOOL DISTRICT 96

SCHOOL MEDICATION AUTHORIZATION FORM

Physician’s Order

Student Name_________________________________________________ Grade/Teacher________________

Medication___________________________________________________ Dosage/Route__________________

Time to be given________________________ Start date______________ End date_____________________

Reason for medication ___________________________Possible side effects____________________________

_______________________________________ ___________________________________________

Physician’s name

Physician’s signature

(print)

phone

date

TO BE COMPLETED BY THE STUDENT’S PARENT/GUARDIAN

I,__________________________________________, parent or guardian of ____________________________ am primarily responsible

for administering medication to my child. However, in a medical emergency or if necessary for the critical health and well-being of my

child, I hereby authorize Kildeer Countryside Community Consolidated School District 96, and its employees and agents, on my behalf and

in my stead, to administer to my child or to allow my child to self-administer while under the supervision of the employees and agents of

District 96, lawfully prescribed medication in the manner described below. I acknowledge that it may be necessary for the administration

of medication to my child and treatment of my child’s condition to be performed by an individual other than the school nurse and

specifically consent to such practices. I will notify the school in writing if the medication is discontinued and will obtain a written order

from the physician if the medication dosage or treatment is changed. I understand that this medication authorization is only effective

for the _____________ school year and will need to be renewed each subsequent school year.

I further acknowledge and agree that, when the lawfully prescribed medication is so administered, I waive any claims I might have against

Kildeer Countryside Community Consolidated School District 96, its employees and agents, arising out of the administration or self-

administration of said medication, regardless of whether the authorization for self-administration of medication was given by me, as the

child’s parent/guardian, or by my child’s physician, physician’s assistant, or advanced practice nurse. In addition, I agree to indemnify and

hold harmless Kildeer Countryside Community Consolidated School District 96, its employees and agents, either jointly or severally, from

and against any and all claims, damages, causes of action or injuries, including reasonable attorney’s fees and costs expended in defense

thereof, incurred or resulting from the administration or self-administration of said medication, except a claim based on willful or wanton

conduct, regardless of whether the authorization for self-administration of medication was given by me, as the child’s parent/guardian, or

by my child’s physician, physician’s assistant, or advanced practice registered nurse.

Parent/Guardian Signature: _____________________________________________________ Date: ____________________

Procedures and Guidelines

1) No school personnel shall administer to any student, nor shall any student possess or consume any prescription or non-

prescription medication except after filing completed Medication Authorization information.

This authorization shall

include: licensed prescriber’s written prescription with child’s name, medication name and dosage, and date of order,

administration instructions with route, time or intervals, duration of prescription, intended effects and possible side effects

and parent written permission.

2) Appropriate containers: Medications and refills are to be in containers that are prescription labeled by a pharmacy or

licensed prescriber to display Rx number, student name, medication, dosage, directions for administration, date and refill

schedule, pharmacy label and name/initials of pharmacist or the manufacturer’s label for non-prescription over the counter

medications.

3) Medication will be administered by the certified school nurse, registered school nurse, school administrators, their

designees and agents. The school nurse or administration retains the discretion to deny requests for administration of

medication.

4) Medication, except for epinephrine, will be stored in a locked cabinet. Those requiring refrigeration will be in a secure

area. Each dose will be recorded in the individual student’s health record. In the event a dose is not administered, the reason

shall be enetered in the record. The parent may be notified if indicated. To assist in the safe monitoring of side effects or

intended effects of the treatment with medication, faculty and staff may be informed regarding the medication plan.

5) To facilitate needed documentation, physician’s orders, any changes in the orders, and parent permissions may be faxed to

your child’s school. It is the parent’s responsibility to assure that all physician orders and permissions are brought to school

and refills provided when needed and to inform the school nurse of any significant changes in the student’s health.

6) Medications remaining at the end of the year will be destroyed unless picked up by the parent.

7) For the safety of all, medication must be brought to the school by the parent or other responsible adult.

School Medication Authorization Form

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