Medication Authorization Form printable pdf download

Highline School District #401

Medication Authorization Form

: __________________

: ____________

: __

Student Name

Birth Date

Sex

: _____________

: ___________

: ___

School

Teacher

Grade

HEALTH CARE PROVIDER completes this section

(please print)

I have determined that the medication named below is necessary during the school day or while the student attends

overnight outdoor school and field trips sponsored by the district:

Diagnosis or reason for medication:______________________________________________________________

Name and Strength of medication: Name: ___________________ Dose: ________________________________

____________________

Tablet/Capsule

Liquid

Inhaler

Nebulizer

Other

If medicine is taken DAILY, specify time: ________________________________________________________

If medicine is to be given WHEN NEEDED, describe indications: _____________________________________

__________________________________________________________________________________________

How soon can it be repeated? ___________________________________________________________________

Length of time this treatment is recommended:

This School Year

Other: _______________

(includes summer)

Significant side effects: _______________________________________________________________________

All Grades: Asthma/Anaphylaxis Meds

. Self Carry Approval (requires School Nurse Approval):

Is child allowed to carry and self-administer “asthma/anaphylaxis meds ”? _______Yes

______No

MD/initials

If yes, I have trained this student in the purpose and appropriate method and frequency of use.

______

Initials

Grades 7-12 only

: for medications that are not controlled substances: (requires School Nurse Approval):

Is child allowed to carry and self-administer this medication?

_______Yes

______No

MD/initials

If yes, I have trained this student in the purpose and appropriate method and frequency of use.

______

Initials

Date: _______________ Health Care Provider Signature: ____________________________________________

Phone #: _________________________ Print Name: _______________________________________________

Fax #: ___________________________ Address:

_______________________________________________________

PARENT/GUARDIAN completes this section:

I request that my child be allowed to take the medication as described above, I understand that is pending school nurse approval.

I request that authorized school staff assist my child in taking the medication(s) described above.

I understand that school staff will attempt to administer medication in a timely manner.

I will provide the medication in the original, properly labeled container.

I give my permission for the exchange of information between the school staff and health care provider.

I understand that my signature indicates my understanding that the school staff shall not incur any liability for any injury when the

medication is administered in accordance with the health care provider’s direction and in accordance with the District Policy and Procedure.

___________ _______________________________ __________________ _________________

(Date)

(Parent/Guardian Signature)

(Daytime Phone)

(Emergency Phone)

School Nurse Approval: _______________________________ (signature)

Date_________________

________________

School Nurse Fax #

Rev. 4-10

(OVER)

Medication Authorization Form

Related Articles

Related forms

Related Categories