Request To Administer Medication At School printable pdf download

Request To Administer Medication At School

Request to Administer Medication at School

The school staff is willing to cooperate with physicians and parents if a child must take

medication during school hours. Please note the following guidelines:

1. A signed physician’s order is required, including:

a. The name of the medication to be administered

b. The prescribed dosage

c. The times when the medication is to be administered

d. The diagnosis or reason the medicine is needed

e. The length of time for which the medication is to be given or for which this order

is in effect.

f. Possible side effects, serious reactions that may occur, and recommended

emergency response.

2. Signed parental permission is also required, including:

a. The name of the medication to be administered

b. The prescribed dosage

c. The times when the medication is to be administered

d. The diagnosis or reason the medicine is needed

e. The length of time for which the medication is to be given or for which this order

is in effect.

3. Medication must be brought to the school nurse in the properly labeled original box,

container or prescription bottle indicating the name of the medication, time to be given

and the recommended dose for your child’s age and size. Most pharmacies will make an

extra bottle for the school if you ask them.

4. It is the responsibility of the student to report to the nurse’s office for the medication at

the prescribed time.

If you have any questions, please feel free to contact your child’s school nurse.

Thank you!

(Please complete other side of form and return)

Request To Administer Medication At School