PERMISSION TO ADMINISTER PRESCRIPTION MEDICATIONS IN SCHOOL

The giving of aspirin or other drugs or medications by school personnel is not recommended. However, upon the written request of a student’s parent/guardian, medication will be administered during school hours subject to the notes below. The school will NOT supply any medication.

Student’s name:_________________________________________________________________

Name of medication: ____________________________________________________________

How long should this medication be administered under the supervision of school personnel?

______________________________________________________________________________

Time (s) to be given at school: _____________________________________________________

Amount to be given: _____________________________________________________________

Reason for medication: ___________________________________________________________

______________________________________________________________________________

Side Effects (if known): __________________________________________________________

______________________________________________________________________________

Name of doctor prescribing the medication: ___________________________________________

Doctor’s telephone number: _______________________________________________________

I give my permission for school personnel to administer the above medication to the above named student.

______________________________________________________________________________

(Signature of parent/guardian)

_____________________________________ ____________________________________

(Date)                                                                 (Telephone #)

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1. The medication must be in the original container with the name of the medication, student, physician, amount, and time (s) to be given.

2. Generally the amount of medication to be kept in the school office should not exceed the dosage for five (5) school days.

3. The student should be responsible for requesting the medication from school personnel and should be instructed by the parent to self-             administer the medication under the supervision of the school personnel.