PERMISSION FORM FOR PRESCRIBED MEDICATION

(APPENDIX A)

Date form received by the school:

Student:

Homeroom:
To be completed by the physician or authorized prescriber:

Reason for medication:

Name of Medication:

Tablet/Capsule Liquid  Inhaler  Nebulizer  Other

Instructions(Schedule and dose to be given at school if cannot be prescribed outside school hours):

Start date form received     Other Date

Stopend of school year      Other Date

For episodic/emergency events only

TO BE SIGNED BY PHYSICIAN:

Physician Name

Address

Phone Number

Physician's Signature

******School is to report concerns about medication or disease to the above physician.******
To be completed by parent/guardian:   (School requires parent/guardian to bring the medication in its original container to the school office.  Students are not permitted to have medication with them at any time while at school.)I give permission for (name of child) to receive the above medication at school according to standard school policy.  Date

Signature of (Parent/Guardian)

Home WorkEmergency
Medications Policy

Medications, including over the counter medications(Tylenol,aspirin,Claritin,Prilosec OTC, ect.), should be given at home whenever possible.  Medications that need to be given three times per day can easily be given before school, after school, and at bedtime.  If medication must be administered at school, it must be in the original container with the prescription label attached and the physician's directions must be included.  All medication must be brought to the office by a parent.  Students are not permitted to have medication with them at any time while at school.

A signed authorization form from the parent is required for school personnel to give a student prescription or over the counter medication. (See Appendix A)   The information o the form must include:  the name of the student, physician's name, physician's address, physician's phone number, type of medicine, dosage, time of day for dose, reason the medication is to be given, release form liability, and parent's telephone at home, work, and emergency.  Physician must sign forms for prescription medication to be administered.

If a child must take medication while at school, please use the following guidelines.

  1. Prescription medication needs to be in the original container.  The student's name, type of medication and doctor's name must be clearly visible.  A note from the physician indication the time and dosage that is to be given should also accompany the medications. (Form - Appendix A)
  2. Please send only the amount to be prescribed at school the original container.   Ask pharmacist to divide prescription if necessary to administer at school.   Medication will not be sent back and forth with the student each day.
  3. Non-prescription medication needs to be in the original container and requires a note from the parent stating that the child has permission to take the drug, explaining why the child need to take the drug, when he/she is to take it, and the dosage amount.   Please send only amount of medication needed.  Medication will not be sent back and forth with the student each day.
  4. The school will keep a log each time a student is given medication, whether it is prescription or non-prescription drugs.
  5. Any inhalers that are sent to school must be accompanied by a note or letter from the physician and parent on when and how may times the inhaler my by used.
  6. Students are not allowed to carry any type of medication with tem during the day - over the counter or prescription.  School requires parent/guardian to bring the medication in its original container to the school office.

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