P.O. B0X 2035
PHYSICIAN / PARENT REQUEST FOR
ADMINISTRATQN OF MEDICINE
OR SPECIAL PROCEDURE BY SCHOOL
PERSONNEL
Special
health care procedures and medication may be administered by school personnel
as follows:
1. When such medication/procedure cannot be accomplished
except during school hours
2. On receipt of this completed form along with the
prescription medication and/or the special equipment
3. Prescribed by a physician/dentist and in the original
container with the pharmacy label— please request the pharmacist to dispense two
labeled bottles of medication - one for home and one for school
Student Name________________________ Date
of Birth_______________
Address___________________________ Teacher
___________________________
Condition for which medication/procedure
is prescribed_______________________
Prescribed medication/procedure
_________________________________________
Dosage and method of administration ______________________________________
Time to administer medication/procedure
at school_______________________________
Precautions or possible unfavorable
reactions to observe for _______________________ _______________________________________________________________________
Date of request__________________ Date of
termination______________
Physician name______________________________________
***Physician signature __________________________________________________
***required
for all treatments and procedures***
Physician address ____________________________Phone
number________________
We (1),
the parent/guardian of _____________________________request the above
medication/procedure
be administer by the school nurse or the designee of the principal to our (my)
child. We (I) give my permission for the
school nurse to contact the above named physician to discuss the medication/procedure
prescribed. We (l) also give my permission
for information regarding this medication/treatment to be shared by the school
nurse with school personnel on a need-to-know basis.
I understand
parents are to pick-up all medications by 3:00 on the last day of school. All
medications remaining after that time will be discarded.
________________________/_________________/______________/______________
Parent/Guardian Name Relationship Home# Work #
________________________/_________________/______________/______________
Parent/Guardian
Name Relationship Home# Work#