Authorization For Administration Of Medication printable pdf download

Authorization For Administration Of Medication

5330 F1/page 1 of 1

AUTHORIZATION FOR ADMINISTRATION OF MEDICATION

Reference: Board of Education Policy 5330

School Year: _________

Name of Student:

____________________________________

Date of Birth: ___________________

Address:

Telephone: _____________________

Physician’s Order:

Diagnosis/Purpose of Medication

Name of Medication

Dosage of Medication:

Frequency:

Time to be Administered at School:

Anticipated Duration:

Pharmacy Name:

Telephone:

Physician’s Signature:

Date:

Physician’s Address:

Telephone:

Noted by the School Nurse:

Date:

The undersigned parent/guardian authorizes Reed City Area Public Schools to administer medication to their child

as ordered by the physician.

It is understood that the undersigned parent/guardian shall immediately notify the school in writing in the event the

prescription is discontinued or modified. Authorization includes permission for school personnel and health care

personnel to contact each other if needed.

The medication must be brought to school by the parent/guardian in a container appropriately labeled by the

pharmacy. Refill of the prescription shall be the responsibility of the parent/guardian. All medication is to be

checked in at the building office immediately at the start of the school day. Parents shall be responsible for

informing the district if the child has experienced side effects from the medication the child is to receive.

Further, the undersigned parent/guardian releases the school district and its employees and shall indemnify Reed

City Area Public Schools and its employees from any foreseeable or unforeseeable liability or damage that may

result to the student from the administration of said medication as prescribed by the physician from this

authorization.

Signature of Parent/Guardian:

Date:

Building:

Telephone Number:

Fax Number:

Reed City High School

(231) 832-2224

(231) 832-2501

Reed City Middle School

(231) 832-6174

(231) 832-6180

G. T. Norman Elementary School

(231) 832-5548

(231) 832-6194

Norman Annex (MSRP “Fun Fours”)

(231) 832-7395

(231) 832-6194

Community Education

(231) 832-5517

(231) 832-6184

4/10/07

Authorization For Administration Of Medication

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