Medication (Prescription)
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
Your answer
Child 1 Date of birth
month / day / year
Your answer
Child 1 Grade
Your answer
MEDICATION
Prescription name, dose, route frequency, time/conditions, duration
Your answer
Reason for
(ex: allergies, cold, migraines, headaches, tooth pain, etc.)
Your answer
When to administer
(ex: every day, as needed)
Your answer
Side effects or concerns
(ex: watch for a rash, keep child calm, etc.)
Your answer
Do you have more children to add?
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