Permission For Medication To Be Given At School Form printable pdf download

SCHOOL DISRICT OF UPPER MORELAND TOWNSHIP

2900 TERWOOD ROAD

WILLOW GROVE, PA

USE OF MEDICATION PERMISSION FORM

The Board of School Directors of Upper Moreland Township, in accordance with the guidelines from the

Pennsylvania Department of Education and Pennsylvania Department of Health, has revised Policy 210 and

has adopted Policy 210.1 concerning the administration of medication in school. For the purposes of these

policies, “Medication” includes Prescription and Over the Counter medicines. The policy states that all

medication brought to school must be in the original labeled container and must be delivered to school by

the parent/guardian. All medications are to be kept in the nurse’s office unless otherwise specified by the

child’s Health Care Provider. Every attempt should be made to dispense medication at home; however, any

medication deemed necessary for the continued treatment of medical conditions will be given during school

hours as prescribed by the child’s Health Care Provider.

Prescription Medication:

-A written/electronic Prescription from the child’s Health Care Provider is required in order to dispense

Prescription medication at school. This form can also be used by your Health Care Provider.

-All Prescription medication must be brought to school in the labeled Pharmacy container.

Over the Counter Medication:

-A written/electronic Prescription from your child’s Health Care Provider is required in order to dispense

Over the Counter medications at school. This form can also be used by your Health Care Provider.

-All Over the Counter medications supplied by parent/guardian must be brought to school in the labeled

container.

ATTENTION PARENT/GUARDIAN: Your signature and the signature of your Health Care

Provider is required on the lower portion of this form. By providing these signatures, you are giving

permission for administration of medication to your child during school hours. Please fill in all sections to

ensure that medication is given correctly.

School District of Upper Moreland Township

PERMISSION FOR MEDICATION TO BE GIVEN AT SCHOOL

Student Name ____________________________________________________

Grade ______________

Name of Medication _______________________________________________

Dosage ____________

(Inhalers, Epi-pens, Insulin pumps and Insulin injections require Action Plan or Treatment Plan attached for

use in school)

Time to be Given ___________________________________

Length of Time ___________________

Reason for Medication ___________________________________________________________________

Parent/Guardian Signature __________________________________Phone___________________ Date ________

Health Care Provider Signature ______________________________________________ Date _______________

Permission to carry Inhaler: yes no MD/DO/NP signature ____________________________________________

Permission to carry Epi-pen: yes no MD/DO/NP signature ___________________________________________

_____________________________________________________________________________________________

Permission for School Nurse to administer Over the Counter:

Acetaminophen yes no

Ibuprofen yes no

Antacid (9th-12

only) yes no

*** PLEASE NOTE: Physicians orders and Parent Permission are valid for the current school year and MUST be

updated each year.

Permission For Medication To Be Given At School Form

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