Request For Administration Of Medication Form
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2USD #384
Blue Valley School District
REQUEST FOR ADMINISTRATION OF MEDICATION
The school district medication policy complies with state regulations. This form must be signed by a physician or a licensed
prescriber and/or parent/guardian. This form must be completed and returned to the school office before any medication;
including over-the-counter drugs can be administered at school. The medication must be in the original container with
appropriate labeling.
_________________________________________________________________________
STUDENT’S NAME
_________________________
__________________
TEACHER or GRADE
SCHOOL YEAR
____________________________________________________________________
NAME OF MEDICATION
________________________________________
________________________________________
DOSAGE
TIME OF DAY TO BE GIVEN
________________________________________
_________________________________________
DATE STARTED
REASON FOR MEDICATION
_____________________________________________________________________________
PERIOD OF TIME TO BE DISPENSED, Example: 10 days, 3 months, Indefinitely
_______________________
__________________________________________________
DATE
PHYSICIAN’S SIGNATURE for
Prescription Medications Only
******************************************************************************
Parental Authorization
I hereby give my permission for ___________________________ to take the above named medication at school as
ordered. I certify that one dose of the above named medication has been given and there was no adverse reaction
from it. I understand that it is my responsibility to furnish this medication. I also understand that any designated
school employee who administers this medication to my child in accordance with written instructions from the
prescribing health care provider and/or parent/guardian shall not be liable for damages as a result of an adverse drug
reaction suffered by the pupil or because of a mislabeled or altered product.
I herby authorize USD #384 School Nurse to exchange information regarding this request with the above named
physician and/or the pharmacy as identified on the affixed pharmacy label as necessary.
_______________________________
_________________
_____________
Parent/Guardian Signature
Daytime Phone
Date
PLEASE NOTE
Students who are on on-going medications must complete a new consent form each school year.
•
Please refer to the School’s Handbook for additional information.
•
Comments:____________________________________________________________________________
*
updated 5/2016
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