SCHOOL MEDICATION PRESCRIBER/PARENT AUTHORIZATION School Year:
STUDENT INFORMATION School:
Student's Name: Date of Birth:
/
Teacher:
Grade:
Age:
/
PRESCRIBER AUTHORIZATION
(To be completed by licensed healthcare provider)
Route:
Medication Name:
Dosage:
Frequency/Time(s) to be given:
Start Date:
Reason for taking medication: Potential side effects/contraindications/adverse reactions: Treatment order in the event of an adverse reaction: SPECIAL INSTRUCTIONS: Is the medication a controlled substance? Is self- medication permitted and recommended? If "yes" I hereby affirm this student has been instructed On proper self-administration of the prescribe medication. Do you recommend this medication be kept "on person" by student? Printed Name of Licensed Healthcare Provider:
pounds
Weight:
0 No known drug allergies---if drug allergies list:
Yes Yes
/
/
❑
No No
❑
No
❑
Yes Phone: (
Stop Date:
/
/
❑
❑
❑
Fax:
) Date:
Signature of Licensed Healthcare Provider:
PARENT AUTHORIZATION I authorize the School Nurse, the registered nurse (RN) or licensed practical nurse (LPN) to administer or to delegate to unlicensed school personnel the task of assisting my child in taking the above medication in accordance with the administrative code practice rules. 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 with the medication. Prescription Medication must be registered with School Nurse or trained Medication Assistants. Prescription medication must be properly labeled with student's name, prescriber's name, name of medication, dosage, time intervals, route of administration and the date of drug's expiration when appropriate. Over the Counter Medication must be registered with the School Nurse or Trained Medication Assistant, OTC's in the original, unopened and sealed container. Local Education Agency Policy for OTC medication to be followed:
Parent's/Guardian's Signature:
/ /
Date:
Phone: ( )
SELF-ADMINISTRATION AUTHORIZATION To be com • leted ONLY if student is authorized to com lete self-care b licensed healthcare rovider.
I authorize and recommend self-medication by my child for the above medication. I also affirm that he/she has been instructed in the proper self-administration of the prescribed medication by his/her attending physician. I shall indemnify and hold harmless the school, the agents of the school, and the local board of education against any claims that may arise relating to my child's selfadministration of prescribed medication(s). Signature of Parent:
Page 1 of 1. Grand Blanc Community Schools. Medication Authorization Form. Permission Form for Administration of Medication at School. Medication includes both prescription and non-prescription medication and includes those taken by mouth, taken by.
Medication includes both prescription and non-prescription medication and includes those taken ... Stop Date: ... Displaying Medication Authorization Form.pdf.
There was a problem previewing this document. Retrying... Download. Connect more apps... Try one of the apps below to open or edit this item. Parent Authorization Form.pdf. Parent Authorization Form.pdf. Open. Extract. Open with. Sign In. Main menu.M
All medication to be administered by school personnel must be delivered in the original and properly labeled container to the school nurse, principal, or the ...
Whoops! There was a problem previewing this document. Retrying... Download ... Medication Authorization Form 2017-2018.pdf. Medication Authorization Form ...
Page 1 of 1. MEDICATION POLICY. 1. Prescription medications should be given at home in the mornings so that your student is comfortable and ready to start. the school day. Most prescription meds are given 2- 3 times a day, at home before school, and
Page 1 of 1. Page 1 of 1. Medication at School Policy.pdf. Medication at School Policy.pdf. Open. Extract. Open with. Sign In. Main menu. Displaying Medication at School Policy.pdf. Page 1 of 1.Missing:
There was a problem previewing this document. Retrying... Download. Connect more apps... Try one of the apps below to open or edit this item. Medication ...
complete the authorization form below and return it to the payroll department. EMPLOYEE AUTHORIZATION. I authorize the St. James R -l School District to ...
Aug 3, 2015 - Personally identifiable information from the following documents in the student's ... Signature of Parent/Guardian ... Signature of Adult Student.
printed on the label. For non-prescriptionâ â(OTC)â âmedicationâ administered to your student at school: â A current school year written parent/guardian ...
I release Jefferson County School District staff from all liability for any injury caused by the administration of the medication in compliance with medication label.
There was a problem previewing this document. Retrying... Download. Connect more apps... Try one of the apps below to open or edit this item. Medication at ...Missing:
G. Reporting and documenting medication error(s). Nasal inhalers, suppositories or non-emergency injections may not be administered by school. staff other than registered nurses or licensed practical nurses. No medication shall be adminis- tered by i
Spanish Version East High School School Parent Compact.pdf. Spanish Version East High School School Parent Compact.pdf. Open. Extract. Open with. Sign In.
St. James R-1 School District Authorization For Direct Deposit_OCR.pdf. St. James R-1 School District Authorization For Direct Deposit_OCR.pdf. Open. Extract.