Leonia Public Schools DOCTOR/ NURSE PRACTITIONER REQUEST/INSTRUCTION FOR MEDICATION TO BE ADMINISTERED BY THE SCHOOL NURSE. To be completed only by a physician or nurse practitioner: Date __________________ The following medication is to be administered to my patient: _____________________________________ Medication: _____________________________

Dose & Route: ________________________________

Time given: _____________________________

Diagnosis: ___________________________________

Significant side effects: ___________________________________________________________________ Length of treatment: ______________________________________________________________________ _________________________________________ Physician/Nurse Practitioner signature

________________________________________ Physician/Nurse Practitioner name (Print)

_________________________________________ School Physician Approval

________________________________________ Date:

----------------------------------------------------------------------------------------------------------------------------------DOCTOR’S REQUEST/INSTRUCTIONS FOR STUDENT SELF-ADMINISTRATION OF MEDICATION FOR A POTENTIALLY LIFE THREATENING ILLNESS. (above section must also be completed) Date: _______________________ The following medication is to be self administered by my patient, _______________________________ I hereby certify that my patient has a life threatening illness and that my patient is capable of and has been instructed in the proper administration of the required medication. Medication _______________________________

Dose & Route: _______________________

_____________________________ MD/Nurse Practitioner Signature

______________________________________________ MD/Nurse Practitioner Signature

____________________________ School Physician Approval

__________________________________________ Date

PARENT REQUEST AND RELEASE – TO BE COMPLETED BY PARENT/GUARDIAN I request my child, ___________________________________ to (receive) (self-administer) the medication designated above. I have been informed by the school district that the school district, its agents, servants and employees shall incur no liability whatsoever as a result of any untoward reaction arising from the administration of medicine to my child. I hereby indemnify and hold harmless the Leonia Board of Education, its agents, servants and employees from any and all claims and shall defend any lawsuit that may arise out of or in connection with the administration of medicine by my child. I shall provide the prescribed medication in the original container. I give the school nurse permission to share pertinent information regarding this medication with school personnel she deems necessary to protect the health and safety of my child. I give permission for the school nurse to contact my child’s doctor regarding this medication.

____________________________________ Parent/Guardian Signature

_______________________________ Date

____________________________________ Dianne Donohue-Hand, RN, School Nurse

_______________________________ Date