STUDENT INFORMATION 

Student’s Name: _______________________________ School: ___________________________________ Date of Birth: _____/_____/______ Age: _________ Grade: ______ Teacher: _____________________ • No known drug allergies---if drug allergies list: ________________________ Weight: ________pounds

PRESCRIBER AUTHORIZATION (To be completed by licensed healthcare provider)

Medication Name: ______________________________ Dosage: ______________Route: ______________ Frequency/Time(s) to be given: ___________________ Start Date: ___/____/____ Stop Date: ___/___/___ Reason for taking medication: __________________________________________

Potential side effects/contraindications/adverse reactions: __________________________________________ Treatment order in the event of an adverse reaction: __________________________________________ SPECIAL INSTRUCTIONS: 

Is the medication a controlled substance? Yes • No •  Is self- medication permitted and recommended? Yes • No •   If “yes” I hereby affirm this student has been instructed

 On proper self-administration of the prescribe medication.  

Do you recommend this medication be kept “on person” by student? Yes • No • Emergency Drug required during Bus Transportation Yes • No •  Cake Icing Gel ONLY for Diabetic Student during Bus Transportation Yes • No •  Printed Name of Licensed Healthcare Provider: ____________________Phone: ( ) _______-_______ Fax: _____-______

Signature of Licensed Healthcare Provider: ___________________________________________ Date: ___________________

PARENT AUTHORIZATION 

I authorize the School Nurse, the registered nurse (RN) or licensed practical nurse (LPN) to administer or to delegate to unlicensed  school personnel the task of assisting my child in taking the above medication in accordance with the administrative code practice  rules. I understand that additional parent/prescriber signed statements will be necessary if the dosage of medication is changed. Prescription Medication must be registered with School Nurse or trained Medication Assistants. Prescription medication must  be properly labeled with student’s name, prescriber’s name, name of medication, dosage, time intervals, route of administration and  the date of drug’s expiration when appropriate.

Over the Counter Medication must be registered with the School Nurse or Trained Medication Assistant, OTC’s in the  original, unopened and sealed container. Local Education Agency Policy for OTC medication to be followed:

Parent’s/Guardian’s Signature: ___________________________Date: ___/___/___ Phone: ( ) _______-_______

SELF-ADMINISTRATION AUTHORIZATION 

(To be completed ONLY if student is authorized to complete self-care by licensed healthcare provider.) 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: ( ) _______-_______