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Intermediate Medication Administration Form
Please complete this form for your child if they need medication administered at school (prescription or over the counter).
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* Indicates required question
Student Name (first and last)
*
Your answer
Grade
*
Choose
4th Grade
5th Grade
6th Grade
Homeroom Teacher
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Medication Name
*
Your answer
Dose:
*
Your answer
Times to be given:
*
Your answer
Method of administration
*
Your answer
Reason for medication
*
Your answer
Prescription # (if not over the counter medication)
Your answer
Pharmacy Name
Your answer
Pharmacy Phone Number
Your answer
Prescribing MD
Your answer
Prescribing MD Phone Number
Your answer
Dates to be given - from ---to (or as needed)
*
Your answer
I understand that an adult must pick up or drop off the medication. At the end of the year, it must be picked up by an adult. We don't store medication over the summer.
*
Yes
I understand that if medication is a partial dose (1/2 tablet), please make sure ALL medication is cut in half before giving to school.
*
Yes
By signing below, I am giving the RN/Health Aide permission to contact my child's doctor as needed in regards to his/her medication. I will also let the RN/Health Aide know of any changes to my child's medication if and when they arise.
*
Your answer
Parent phone number
*
Your answer
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