Prescription Medication Request: Long Term printable pdf download

RESCRIPTION

EDICATION

EQUEST

ONG

ERM

______________________

__________________________ S

TUDENT

CHOOL

Note: Prescription Medication must be in the original container indicating the following

information: student name, dosage, healthcare provider, pharmacy, date issued, and

prescription number.

: I request that the prescription medication listed below be given

ARENT

TATEMENT

to my child named above.

• I understand that a picture of my child will be placed on the medication card.

• I authorize and delegate that in the absence of the school nurse, other school

personnel be trained administer medication.

• I agree to defend and hold the school district employees harmless from any

liability for the results of the medication or the manner in which it is

administered, and to defend and indemnify the school district and its employees

for any liability arising out of these arrangements.

• I will notify the school immediately if the medication is changed and

understand that the nurse may contact the health care provider or pharmacist

regarding this medication.

•

I understand that this medication will be destroyed unless picked up by the end

of the last student school day of this year per federal DEA requirements.

Parent/Guardian Signature___________________________Date__________________

Home phone ____________________ Work/Emergency Phone____________________

Other medications your child is taking________________________________________

: This medication is required during school hours

EALTHCARE

ROVIDER

TATEMENT

to improve or maintain the health of this student. The nurse may contact me regarding

this medication. The above named child should receive prescribed medication for the

following condition: _______________________________________________________

• Medication________________________________________________________

• Prescribed daily dosage ______________________________________________

• Time and dosage given at school_______________________________________

• Beginning date of medication________________ Ending Date______________

• Possible side effects_________________________________________________

Healthcare Provider Signature ______________________ Date ___________________

Printed Name __________________________________Phone_____________________

Healthcare Provider Address________________________________________________

Anchorage School District

Page 1 of 1

Nursing & Health Services

NUR # 0525

Revised 6/2013

Prescription Medication Request: Long Term

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