Medication (Prescription)

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As a part of the Wisconsin Statute Chapter 118.29, Administration of Drug to Pupils and Emergency Care, school districts are required to have permission from a medical provider and parent to administer medications at school. As part of this authorization form, school district employees may contact the medical provider with questions regarding the medication administration including clarification regarding dosage, side effects or indication of the medication(s) with parent permission.

Christ the Lord School Personnel will notify the parent/guardians when medication is administered. The prescription medication authorization form must be renewed each year or more often if changes in dosage occur.

STUDENT

Child 1 Name *

first and last name

Child 1 Date of birth *

month / day / year

Child 1 Grade *

MEDICATION

Prescription name, dose, route frequency, time/conditions, duration

Reason for

(ex: allergies, cold, migraines, headaches, tooth pain, etc.)

When to administer

(ex: every day, as needed)

Side effects or concerns

(ex: watch for a rash, keep child calm, etc.)

Do you have more children to add?

Yes

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