Medication Administration Record - Allergy/epi-Pen Form (Page 2 of 2) in pdf

Medication Administration Record - Allergy/epi-Pen Form Page 2

School Year _________

Medication Administration Record – Allergy/Epi-pen Form

Parent/ Guardian Authorization:

1. I authorize the nurse and in her absences the school board’s designees to administer the above medication.

2. I will submit a new form if there is any change in the medication order (time, dose, or discontinuation of med)

3. I authorize the nurse to speak with the above named prescriber regarding my child’s health and treatment as they

pertain to the above medication and/or my child’s education and behavioral management needs.

4. I understand that ALL prescription medication must be in the original container. Medication containers should be

labeled with the child’s name, medication, dose, strength, time, route, and prescriber’s name.

5. I understand that any over-the-counter medications (e.g. Tylenol, Advil, Lactaid, or topical creams) must have a

medication administration form and come to school in the original container labeled with the child’s name.

6. I agree to transport the medication to/from school (students may not transport medication to school except for

asthma inhalers and Epi-pens).

7. I understand that this form is valid for one year only. Form expires at the end of the current school year.

Parent/Guardian Signature:

Date:

Phone#:

8401 Montgomery Road  Cincinnati, OH 45236   Phone: 513-984-3770  Fax: 513-984-3787

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Medication Administration Record - Allergy/epi-Pen Form Page 2