Authorization For Self-Carry/administration Of Medicine - Physician / Prescribing Health Care Provider Order Form
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1SIERRA VISTA PUBLIC SCHOOLS
AUTHORIZATION FOR SELF-CARRY/ADMINISTRATION OF MEDICINE
AT SCHOOL AND AFTER- SCHOOL ACTIVITIES
Board of Education policy permits a responsible, trained student to carry and/or self-administer medication for
asthma (wheezing), severe allergic (anaphylactic) reaction, or diabetes on his/her person for immediate use in a life-threatening
situation with written order of physician, parent request, school nurse and principal approvals.
PHYSICIAN / PRESCRIBING HEALTH CARE PROVIDER ORDER
Name of Student____________________________________DOB_____________School_________________
Address____________________________________________________________ Grade__________________
Condition for which the medication is administered________________________________________________
Name of medication, dose and method administered________________________________________________
Time of indication for administration____________________________________________________________
Is this a controlled drug? Yes__________
No ____________
Side effects to be noted / reported_______________________________________________________________
Other recommendations______________________________________________________________________
Duration (dates) of administration: From________________ To_______________(limit one school year)
PARENT / GUARDIAN AUTHORIZATION
I request that my child, named above, be permitted to : carry_______ self-administer_______the above ordered medication. I take
responsibility for this permission. I understand that the medication must be in the original pharmacy container, labeled with name of
student, prescribing health care provider, and medication: date of original prescription: strength and dose of medication: and direction
for use. No more than a 45 school day supply of medication will be kept at school. This medication will be destroyed unless picked
up within one week after the end of the school year or end of the medical order.
___________________________________ ______________ ____________________________
____________
Parent Signature
Date
Student Signature
Date
_______________________________________________________________________________________________
Parent Telephone Numbers
We accept the parent request and physician statement. We will permit and assist the student to be responsible, but reserve the right to
withdraw the privilege if the student shows signs of irresponsible behavior or there is a safety risk. We will contact the parent as soon
as possible in this event.
______________________________ ____________ _______________________________ ___________
School Nurse Signature
Date
Principal Signature
Date
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