9400 South Sawyer *
SCHOOL
MEDICATION AUTHORIZATION
To be completed by the child’s parent(s)/guardian(s)
and physician and kept in the school nurse’s office or in the absence of a
school nurse, the Building Principal’s office:
Student’s Name:___________________________________Birth
Date:___________________________
Address:______________________________________________________________________________
Home Phone:_______________________________Emergency
Phone:___________________________
School:__________________________Grade:___________Teacher:_____________________________
To be completed by the student’s physician:
Physician’s Printed Name:_________________________________________________________________
Office Address:__________________________________________________________________________
Office Phone:__________________________________Emergency
Phone:__________________________
Medication:_____________________________________________________________________________
Dosage:___________________________________Frequency:___________________________________
Time medication is to be administered
or under what circumstances:________________________________
Prescription Date:_____________Order
Date:_________________ Discontinuation Date:_______________
Diagnosis requiring medication:_____________________________________________________________
Intended effect of this
medication:___________________________________________________________
Must this medication be administered during the school day in order to allow the child to attend school or to address the student’s medical conditions? q Yes q No
Expected side effects, if any:_______________________________________________________________
Time Interval for reevaluation:______________________________________________________________
Other medication student is
receiving:________________________________________________________
Physician’s Signature:_________________________________________Date:_______________________
9400
South Sawyer *
SCHOOL
MEDICATION AUTHORIZATION
To be completed by Parent(s)/Guardian(s):
I authorize the School
District and its employees and agents, to allow my child or ward to possess and
use his or her asthma medication (1) while in school, (2) while at
school-sponsored activity, (3) while under the supervision of school personnel,
or (4) before or after normal school activities, such as while in before-school
or after-school care or school-operated property.
If you agree please initial:_______________
(Parent(s)/Guardian(s) initials)
By signing below, I agree:
That I am
primarily responsible for administering medication to my child. However,, in
the event that I am unable to do so or in the event of a medical emergency, I
hereby authorize the School District and its employee and agents, in my behalf
and stead, to administer or attempt to administer to my child (or to allow my
child to self-administer, while under the supervision of the employees and
agents of the School District), lawfully prescribed medication in the manner
described above. I acknowledge that it
may be necessary for the administration of medication to my child to be
performed by an individual other than a school nurse, and specifically consent
to such practices, and to indemnify and hold harmless the School District and
its employees and agents against any claims, except a claim based on willful
and wanton conduct, arising out of the self-administration of medication by the
pupil.
_______________________________________
_____________________________________
Parent/Guardian Printed Name
Parent/Guardian Printed Name
___________________________________________
___________________________________________
Parent/Guardian Signature* Parent/Guardian
Signature*
Both parents/guardians, if
available should sign