Request For Administration Of Medication Form (Page 2 of 2) in pdf

USD 384 Blue Valley/Randolph

Permission for Self-Administered Prescription Medication

Inhaler, Epi-pen, Insulin, only

Student Name_____________________________________

Grade_________

Medication________________________________________

Reason_________

Dosage___________________

Time_______________

Possible Side Effects__________________________________________________

Date Medication started_____________

Length of time to be given__________

______Student is both capable and responsible for carrying and self-administering this

medication as prescribed.

Signature of Prescriber________________________________

Date__________

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I am the lawful custodian of____________________________. I give my permission for him/her to take

the above prescribed medication while at school. I certify that one does of this medication has been given and

my child did not suffer any adverse reactions. I understand that it is my responsibility to furnish this

medication. I also understand that any designated school employee who assists with administering this

medication to my child in accordance with written instructions from the prescribing health care provider shall

not be liable for damages as a result of any adverse reactions suffered by my child due to to mislabeled or

altered product. I hereby authorize USD #384 School Nurse to exchange information regarding this request

with the health care provider and/or the pharmacist as necessary.

Signature of Parent___________________________________ Date____________

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_____I accept the responsibility of carrying and administering my own

Inhaler, Epi-pen, or Insulin.

This means I will: _____Have this medication with me at all times.

_____ Follow the doctor’s orders for taking and/or using this medication

_____ Not allow other students to use my medication

_____ Label my medication with my full name and name of medication.

Signature of Student____________________________________ Date__________

Note:

The school district medication policy complies with state regulations. Self-Administration Medication

DOES NOT include Over-the-Counter Medications or other prescription medications such as Ritalin, Adderall,

Antibiotics, etc. Self-Administration Medication Forms are to be kept on file in School Office and must be

renewed at the beginning of each school year.

updated 2016

Request For Administration Of Medication Form Page 2