Permit To Administer/ Distribute Required Medications During School Hours Form printable pdf download

CHAMPAIGN COMMUNITY SCHOOLS

Permit for Authorized Personnel to Administer/ Distribute Required Medications During School Hours

THIS PERMISSION MUST BE RENEWED ANNUALLY.

Child’s Name __________________________________

School _____________________________________

(TO BE COMPLETED BY PHYSICIAN)

NOTE:

THE DISTRICT WILL LIMIT THE MEDICATIONS IT WILL DISPENSE TO THAT WHERE FAILURE TO TAKE PRESCRIBED

MEDICATION COULD JEOPARDIZE THE STUDENT’S HEALTH AND/OR EDUCATION. THE DISTRICT WILL ADMINISTER

ADD/ADHD MEDICATIONS, ASTHMA, SEIZURE, DIABETIC MEDICATIONS AND OTHER MEDICATIONS SUBJECT TO THE

DISCRETION TO REJECT A REQUEST.

Date

_______________________________

This child, _____________________________________________________________________ is under my medical care

for __________________________________________________________________________, and medication is required

during the school day for the purpose of _________________________________________________________________ .

Name of Drug

Dosage

Frequency

Time to be Given

Duration

Side Effects

at School

Signature of Physician ______________________________________

-School Use Only –

Printed Name of Physician ___________________________________

Approved:

Yes ______

Address __________________________________________________

No ______

_________________________________________________________

(City)

(State)

(ZIP Code)

_______________________________

Principal

Date

Emergency Telephone Number _______________________________

(TO BE COMPLETED BY PARENT OR LEGAL GUARDIAN)

I, _______________________, give permission for my child to receive the above medication(s) as directed by the physician. The

medication will be sent to school in a container appropriately labeled by the pharmacy. I will notify the school in writing if the

medication is discontinued. Also, I will obtain a written doctor’s order if the medication dosage is changed. I will bring the

medication to the school principal or designee.

I hereby authorize District Health Staff to contact the medical provider named here _______________________________

regarding this medication and to release information regarding my child (named above) to said provider. I hereby authorize the

medical provider to release information about my child and this medication to District Health Staff regarding any medical concerns

about this medication order.

I also give permission for the School Administration/ School Nurse to contact the prescribing health professional about the

administration of this medicine. I certify that I have administered at least one dose of the medicine to my child without adverse

effects.

Parent’s Signature _____________________________________________

Date _______________________________

Address _____________________________________________________

_____________________________________________________________

(City)

(State)

(ZIP Code)

Version: 2014

Cell Phone ___________________ Home Phone ____________________

Permit To Administer/ Distribute Required Medications During School Hours Form

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