Authorization For Medication Administration At School Form

PRINCE GEORGE COUNTY PUBLIC SCHOOLS

Aut hor i zat i on f or Me di c at i on Adm i nis t r at i on at Sc hool

W i t h t h e e x c e p t i o n o f a c e t a m i n o p h e n , i b u p r o f e n , a n d n a p r o x e n , a l l m e d i c a t i o n a d m i n i s t e r e d a t s c h o o l

s h a l l r e q u i r e t h e c o m p l e t i o n o f t h i s a u t h o r i z a t i o n f o r m b y p a r e n t / g u a r d i a n a n d l i c e n s e d p r e s c r i b e r .

( A s e p a r a t e p a r e n t a u t h o r i z a t i o n f o r m i s r e q u i r e d f o r t h e a f o r e m e n t i o n e d m e d i c a t i o n s . )

P ARENT/ GU AR DI A N SEC TI O N

Student __________________________________ DOB____________ Medication Allergies ____________________

I, ____________________________________________, parent or legal guardian of above student, request that the

principal’s designee at _________________________________ School administer the below prescribed medication to

my child. 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.

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

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Over-the-counter medication must be in the original, unopened container, labeled with student’s name.

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

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

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

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Parent/Guardian Signature ______________________________________________ Date _______________________

Parent/Guardian PRINTED Name _____________________________________________________________________

Home Phone ______________________ Work Phone _____________________ Cell Phone _____________________

LI CENS ED P RES CR I B ER SECTI O N

(Must be completed by Physician / Dentist / Nurse Practitioner / Physician Assistant)

I certify that, in my opinion, it is medically necessary that the medication prescribed below be administered to

___________________________________________

during school hours and that this medication

(Name of Student)

may be administered by school personnel.

Prescription:

Medication

_________________________________________________________________________

:

Dosage, Time and Route

______________________________________________________________

:

Duration

___________________________________ Date of Prescription

______________________

:

:

Diagnosis Requiring Medication

________________________________________________________

:

Possible Side Effects

: ________________________________________________________________________

Special Handling Instructions

:_________________________________________________________________

Prescriber Signature____________________________________________________ Date _______________________

Prescriber PRINTED Name __________________________________________________________________________

Prescriber Phone _______________________________________ Fax _______________________________________

Prescriber Address _________________________________________________________________________________

HSM 0007-0809