Medication Drop Off
Please select a time slot for medication drop off.

You will be able to drop medication off during your scheduled Open House time.
Sign in to Google to save your progress. Learn more
Name of Parent/Guardian Dropping Medication Off *
Phone Number of Parent/Guardian Dropping Medication Off *
Name of Student *
Grade of Student *
Please select a time slot from the options below: *
Parent/Guardian Responsibilities
The parent/guardian must provide the school with:
• Pharmacy label must be exact to include medication dosage, time, and interval. No ranges.
• A complete CCS Confidential School Health Form.
• Written parent/guardian consent (schools operate in loco parentis; therefore 18-yearold students who are living with their parent/guardian should still have parent/
guardian consent).
• Medications, orders, consents, and supplies.
• A written provider order on an approved CCS medication form(s) and supplies to
meet requirements of the order.
• Sign release of liability.
• Sign authorization for school to communicate with student’s health care provider, if
necessary.
• Provide the medication(s) and any needed supplies or equipment for administration
(e.g., syringes and needles, spacers, etc.).
• Check-in and sign out medicines with medication clerk.
• Count/measure medications with the medication clerk before acceptance.
• Bring all medications in an original pharmacy labeled container that matches the
physician’s order.
• It is the responsibility of the student’s parent/guardian to replace used and expired
medication.
• The parent/guardian must deliver backup medicine before a student is allowed to
self-carry with emergency medication.
• The parent/guardian will have 30 calendar days to provide the school with
appropriate documentation and medication to meet the medical need.
• The parent/guardian must present emergency medications within 30 calendar days
to school medication clerk. A physician’s order must accompany all requests from
the parent/guardian to administer medication.
• The parent/guardian of students who self-medicate during the school day are held
liable if another student takes the medication. The school system will assume no
liability for students who self-medicate.
• Backup emergency medication is required by House Bill 496 parent/guardian must
provide backup medicine for all students who self-administer.
• Communicate any changes in a student’s health status and or medication regime.
• A parent/guardian may sign out their student’s medication from the school at any
time.
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Cumberland County Schools. Report Abuse