SCHOOL MEDICATION PRESCRIBER/PARENT
AUTHORIZATION
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STUDENT
INFORMATION Student’s Name
__________________________________________________Date of Birth
_______________________________ School ________________________________ Grade __________ List any known drug allergies/reactions
__________________________________Height (inches)_ ______ Weight (lbs)
_______ |
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PRESCRIBER
AUTHORIZATION Name of Medication
_____________________________________ Reason for Taking ___________________________________ Dosage _______________ Route
________________________ Frequency/Time(s) to be given
____________________________ Begin Medication __________________________________
Stop Medication __________________________________________ Date
Date Special Instructions: Does medication require
refrigeration? Yes □ No □ Is the medication a
controlled substance? Yes □ No □ Is self-medication
permitted and recommended for this student?
Yes □ No □ If yes, do you recommend
this medication be kept “on person” by the student? Yes □ No □ Potential Side
Effects/Contradictions/Adverse Reactions
___________________________________________________________ Treatment
Order in the event of an adverse reaction:
_____________________________________________________________ (Attach
additional sheet or use the back of this form if necessary) I hereby
affirm that this student has been instructed in the proper
self-administration of the prescribed medication (s). ________________________________________ __________________ _____________________ ____________________ Signature of Prescriber (please
print) Date Phone Fax |
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PARENT
AUTHORIZATION I authorize the School
Nurse, the registered nurse (RN) or licensed practical nurse (LPN) to
delegate to unlicensed school personnel the task of assisting my child in
taking the above medication. I
understand that additional parent/prescriber signed statements will be
necessary if the dosage of medication is changed. I also authorize the School Nurse to talk
with the prescriber or pharmacist should a question come up about the
medication. Medication must be
registered with the principal, his/her designee, or the school nurse. It must be in the original, unopened,
sealed container and be properly labeled with the student’s name,
prescriber’s name, date of prescription, name of medication, dosage,
strength, time interval, route of administration and the date of drug
expiration when appropriate. ________________________________________ __________________ _____________________ ____________________ Signature of Parent Date Phone Cell |
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SELF-ADMINISTRATION
AUTHORIZATION I authorize and recommend
self-medication by my child for the above medication. I
also affirm that he/she has been instructed in the proper self-administration
of the prescribed medication by his/her attending physician. I shall indemnify and hold harmless the
school, the agents of the school, and the local board of education against
any claims that may arise relating to my child’s self-administration of
prescribed medication(s). ________________________________________ __________________ _____________________ ____________________ Signature of Parent
Date
Phone Cell |