PHYSICIAN’S STATEMENT
I request that medication as prescribed be administered by school officials
to:
STUDENT MEDICATION:
Name Name
Address Dosage
School Date medication begins
Grade Teacher Date medication ends
Reactions, if any, to be reported to physician:
PHYSICIAN
Signature Date
Address
Telephone Number
* Parent/Guardian must notify the school if any information contained in
this form should change.
PARENT PERMISSION
FOR NON-PRESCRIPTION MEDICATION
I hereby request that non-prescription medication as described by the
Governing Board policy be administered to my daughter/son, . I will notify
the school to rescind permission.
Homeroom Teacher Parent/Guardian Signature Date
Telephone Number
GUIDELINES FOR DEVELOPMENT OF REGULATIONS
REGARDING DISPENSATION OF MEDICATION
If medication must be administered during school hours, the Governing
Board appoints the principal or his designee and school nurse to
administer medication according to the following guidelines.
The prescription medicine shall be brought to the principal’s office and
the principal or his designee shall direct the student to the school nurse
(if available). The medication in a doctor-or-pharmacy labeled container
is to be left with the nurse, along with:
1. a written request by parents/guardian that the medicine be administered
and
2. a written statement by the physician containing the following
information:
A. name and address of the student;
B. school and class in which the student is enrolled;
C. name of the medicine and the dosage to be administered;
D. the time or interval which each dosage is to be administered;
E. the dates the administration of the drug is to begin and end;
F. any severe reactions that should be reported to the physician;
G. any special instructions for administering the medication;
H. an agreement that the parent/guardian will submit a revised statement
if any of the above information changes and;
I. a telephone number where the parent/guardian may be reached should it
become necessary.
(Approval date: June 21, 2001)
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