School Medication Prescriber / Parent Authorization
STUDENT INFORMATION
Student’s Name __________________________________ School Year_______________
School: Elba Elementary School Grade ___________ Teacher___________________
List any known drug allergies / reactions _______________________________________
Height ________________ Weight ____________________
PRESCRIBER AUTHORIZATION
Name of Medication _________________________ Reason for Taking (Optional) ____________________
Dosage ____________________ Route _____________________ Frequency / time to be given __________
Begin Medication ___________________________ Stop Medication ________________________________
Date Date
Special Instructions:
Does medication require refrigeration? Yes_________ No __________
Is the mediation a controlled substance? Yes _________ No _________
Is self-mediation permitted and recommended for the student? Yes ________ No ___________
If asthma inhaler or emergency mediation, do you recommend this medication be kept “on person” by the student? Yes ___________ No __________
Potential Side Effects / Contraindications/ Adverse Reactions __________________________________________
___________________________________________________________________________________________
____________________________________________________________________________________________
Treatment Order in the event of an adverse reaction: (Attach additional sheet or use the back of this form if necessary)___________________________________________________________________________________
___________________________________________________________________________________________
__________________________ ____________ __________________ _______________________
Signature of Prescriber Date Phone Fax
Parent authorization
I authorize the School Nurse, the registered nurse (RN) or licensed practical nurse (LPN) to delegate to unlicensed school personnel the task of assisting my child in taking the above medications. I understand that additional parent / prescriber signed statements will be necessary if the dosage of medication is changed. I also authorize the School Nurse to talk with the prescriber or pharmacist should a question come up about the medication.
Medication must be registered with the principal, his / her designee, or the school nurse. It must be in the original container and be properly labeled with the student’s name, prescriber’s name, date of prescription, name of medication, dosage, strength, time interval, route of administration, and the date of drug’s expiration when appropriate.
____________________________ _______________________ _________________
Signature of Parent or Guardian Date Phone
I authorize and recommend self-medication by my child for the above medication.
_______________________________________ ________________________
Signature of Parent or Guardian Date
If any questions pr problems arise, call me at ______________________ (Home)
__________________________ (Work) ________________________ (Cell)
STUDENT INFORMATION
Student’s Name __________________________________ School Year_______________
School: Elba Elementary School Grade ___________ Teacher___________________
List any known drug allergies / reactions _______________________________________
Height ________________ Weight ____________________
PRESCRIBER AUTHORIZATION
Name of Medication _________________________ Reason for Taking (Optional) ____________________
Dosage ____________________ Route _____________________ Frequency / time to be given __________
Begin Medication ___________________________ Stop Medication ________________________________
Date Date
Special Instructions:
Does medication require refrigeration? Yes_________ No __________
Is the mediation a controlled substance? Yes _________ No _________
Is self-mediation permitted and recommended for the student? Yes ________ No ___________
If asthma inhaler or emergency mediation, do you recommend this medication be kept “on person” by the student? Yes ___________ No __________
Potential Side Effects / Contraindications/ Adverse Reactions __________________________________________
___________________________________________________________________________________________
____________________________________________________________________________________________
Treatment Order in the event of an adverse reaction: (Attach additional sheet or use the back of this form if necessary)___________________________________________________________________________________
___________________________________________________________________________________________
__________________________ ____________ __________________ _______________________
Signature of Prescriber Date Phone Fax
Parent authorization
I authorize the School Nurse, the registered nurse (RN) or licensed practical nurse (LPN) to delegate to unlicensed school personnel the task of assisting my child in taking the above medications. I understand that additional parent / prescriber signed statements will be necessary if the dosage of medication is changed. I also authorize the School Nurse to talk with the prescriber or pharmacist should a question come up about the medication.
Medication must be registered with the principal, his / her designee, or the school nurse. It must be in the original container and be properly labeled with the student’s name, prescriber’s name, date of prescription, name of medication, dosage, strength, time interval, route of administration, and the date of drug’s expiration when appropriate.
____________________________ _______________________ _________________
Signature of Parent or Guardian Date Phone
I authorize and recommend self-medication by my child for the above medication.
_______________________________________ ________________________
Signature of Parent or Guardian Date
If any questions pr problems arise, call me at ______________________ (Home)
__________________________ (Work) ________________________ (Cell)