Physician Order And Parent/guardian Authorization For Self Medication Administration

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STUDENTS
09.2241 AP.2
PHYSICIAN ORDER AND PARENT/GUARDIAN AUTHORIZATION
FOR SELF MEDICATION ADMINISTRATION
(Please complete one form for each medication.)
EXAMPLE FORM ONLY
Student’s Name: ________________________________________________ DOB: ______________
Allergies: ___________________________________________________________________________
Medication: ________________________________________
Dosage: ________________________
Reason for medication or diagnosis: ____________________________________________________
School: _____________________________________________________ School Year: ___________
In order for students to self-administer medication at school, the Parent/Guardian shall provide this signed
authorization form. Also, a Physician’s Order (see box below) is required for students to self-administer medication.
Please be sure to complete ALL of the information on this authorization form before returning it to school. This
authorization is valid for one school year and must be renewed at the beginning of each new school year.
*
It is recommended that only middle and high school students are allowed to carry and self-administer their
own medication. For elementary age children, arrangements can be made to keep inhalers or emergency
medications in the classroom. The student’s teacher will provide monitoring for the child’s safety.
Please note, per policy, no student may carry or self-administer a controlled substance.
PHYSICIAN’S ORDER
1. I have examined this student for (diagnosis): _______________________________________________________
and have determined that he/she requires medication during school hours.
2. Name of Medication _______________________________ 3. Dosage & Route: _________________________
4. I believe this student is able to carry and administer his or her own medication (excluding controlled substances)
at the appropriate time and in the appropriate way. Please check: ____YES
_____ NO
I understand that self-administered medication is not provided by or monitored by the School Nurse or school staff.
Physician’s Signature: _____________________________________
Date: _____ / _____ / _____
Printed Name: ____________________________________________
Phone: ______________________
PARENT/GUARDIAN STATEMENT
I, the undersigned Parent(s)Guardian(s) of ______________________________________ give consent
for **my student to self-administer the above medication(s). I understand the Fayette County Board of
Education Medication Policies & Procedures (09.2241) are readily available for me to read. I hereby agree
to release and hold the school staff free and harmless for any claims, demands, or suits for damages from
any injury or complication that may result from such treatment. I have read this consent and understand all
its terms. I sign it voluntarily and with full knowledge of its significance. I understand that self-administered
medication is not provided by or monitored by the School Nurse or school staff.
The School Nurse reserves the right to monitor student periodically during the school year.
*
Parent / Student are responsible to have the medication available at school.
X ______________________________________________
____ / ____ / ____
(Parent/Guardian Signature)
Date
Home Phone: _______________________Work: ____________________Cell: ____________________
Reviewed by: _________________________________ RN
Date: ____________________
FAYETTE COUNTY PUBLIC SCHOOLS – MEDICATION AUTHORIZATION FORM – SELF

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