Medication Authorization For Cms Students Form/authorization For Self-Medication By Cms Students Form

MEDICATION AUTHORIZATION FOR CMS STUDENTS

School Name___________________________________Telephone_____________________Fax_______________________

To the parent or guardian of ________________________________________Birthdate____________________________

In order to help protect your child's health, your consent and written authorization from a licensed healthcare provider are

required when it is necessary for your child to receive either prescription or non-prescription medicines in the Charlotte-

Mecklenburg Schools. No medications will be given to your child at school until this authorization has been received. A

separate form is required for each medicine. New authorization forms are required every year at the beginning of school,

whenever the dose or directions change, or when a new medicine is prescribed. It is your responsibility to provide all

medicines to be given at school. Each medicine must be in an appropriately labeled original container from the pharmacy or

healthcare provider's office. Most pharmacies will provide an extra container for school use upon request. Administration of

non-prescription medicines at school is discouraged.

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Parent or Guardian's Permission: I give permission for my child to receive this medicine described below during school

hours. I understand that it is my responsibility to purchase and supply this medicine. On behalf of my child I absolve the

Charlotte-Mecklenburg Board of Education and their agents and employees from any and all liability whatsoever that may

result from my child taking this medicine at school.

_______________________________________________ _____________________________________________________

Signature of parent or guardian

Date

Contact numbers (pager or mobile, work, home telephone #s)

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FOR LICENSED HEALTHCARE PROFESSIONAL USE ONLY: please write legibly using lay terms

Medication prescribed: _______________________________________Strength/Dose: _______________________________

Specific Directions [

(include exact amount to give, at what time and/or how often, relationship to meals, specific indications, e.g. if prn (as

needed)]

Purpose of Medication

: ____________________________________________________________________________________________

Relationship to meals, if applicable: ________________________________________________________________________

How often and at what time (hour): _________________________________________________________________________

Specify side effects or adverse reactions: ____________________________________________________________________

Other instructions: (including emergency situations): ___________________________________________________________

Please check all appropriate items. If either of the first two items is checked, page 2 of this form must be completed.

Please allow this student to self-administer this medication while at school during school hours. (must complete page 2 of

this form.)

This student should carry the medication with him/her at all times during the school day, while at school-sponsored events,

or while in transit to or from school or school-sponsored activities. (must complete page 2 of this form.)

This medication is to be used for emergencies only.

It is necessary for this student to receive this medication during school hours in order to maintain or improve health and to

benefit from school attendance. Please notify the principal and/or school nurse and parents/guardians if there are any

problems.

_________________________________________________ _________________________ _________________________

Signature of Health care provider

Date

Telephone

Fax

______________________________________________ ______________________________________________________

Please print Provider’s last name

Practice name or address

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FOR SCHOOL USE ONLY:

Date Received/By: _____________________________________School Health Nurse Review: _________________________

Rev 8/06 lp

Med 1