Form Bebco 2804-13 - Parent'S Request To Administer Medication In School
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1BALTIMORE COUNTY PUBLIC SCHOOLS
BALTIMORE COUNTY DEPARTMENT OF HEALTH
Towson, Maryland 21204
Baltimore, Maryland 21212
PARENT’S REQUEST TO ADMINISTER MEDICATION IN SCHOOL
Dear Parent/Legal Guardian:
To request medication administration at school, please note:
This form must be completed and signed by you and your child’s medical provider.
A new form is needed for all changes in medication, dose, or time.
The medication should be brought to school by a parent/guardian or responsible adult.
The medication container must be labeled by the pharmacy with the student’s name, prescriber’s name, name of medication, dosage, route,
conditions for storage, prescription date, and expiration date.
Unless otherwise specified, medication order is valid for the entire school year.
Expired and discontinued medication not picked up by the last day of school will be destroyed.
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EALTH
ARE
ROVIDER
S
NSTRUCTIONS FOR
IVING
EDICATION IN
CHOOL
Name of Student:
_________________________________
Date of Birth: __________________
Grade: ________
Condition for which medication is being administered: _________________________________________________________________
Medication Name: __________________________________
Dose: ___________________
Route: _________________________
Time/Frequency of administration: ______________________________________ If PRN, frequency: ___________________________
If PRN, for what symptoms: ______________________________________________________________________________________
Special/Emergency Instructions:___________________________________________________________________________________
Prescriber’s Name/Title: _____________________________________________________ Telephone: _________________________
Address: _________________________________________________________________
Fax: ______________________________
Prescriber’s Signature: _________________________________________________
Date: ______________________________
(Original signature or signature stamp ONLY)
P
/G
A
ARENT
UARDIAN
UTHORIZATION
I/We request designated school personnel to administer the medication as prescribed by the above prescriber. I/We certify that I/We have
legal authority to consent to medical treatment for the student named above, including the administration of medication at school. (I/We
understand that at the end of the school year, an adult must pick up the medication, otherwise it will be discarded.) I/We authorize the
school nurse to communicate with the health care provider.
Parent/Guardian Signature:___________________________________________________ Date: ______________________________
Home Phone #: _________________________ Cell Phone #: ________________________ Work Phone # _____________________
F
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, T
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G
W
A
U
Y
I
O
W
:
OR
LTERED
CHOOL
CHEDULES
HE FOLLOWING
EDICATION
UIDELINES
ILL
PPLY
NLESS
OU
NDICATE
THERWISE IN
RITING
One hour late opening: doses will be given as usual, with minor modifications in timing, if needed.
Two hour late opening: medications scheduled to be given before 10 a.m. will not be given in school; other doses will be given
according to the prescribed schedule.
Three hour early dismissal: medications scheduled to be given at lunchtime or later will not be given.
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-I
/
I
UTHORIZATION FOR
TUDENT TO
ARRY
PINEPHRINE
UTO
NJECTOR AND
OR
NHALER
Prescriber Authorization ___________________________________
______________________
Signature
Date
Parent/Guardian Authorization ______________________________
______________________
Signature
Date
TO BE COMPLETED BY SCHOOL
Date form received at school :________________________
Received by: _________________________________________________
BEBCO 2804-13
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