JLCD-E2 - Administration of Medication to Students Authorization Form
JLCD-E2 - Administration of Medication to Students Authorization Form
To be completed by the child’s Health Care Provider and Parent/Guardian.
Please complete this form to allow the school nurse or designated school staff member to administer the named medication. All medication must be brought to school by an adult and will be kept in the school nurse’s office. The medication must come in the original container with the student’s name and prescription instructions labeled. This must be renewed annually or updated with changes to prescription.
School Year: __________ to __________
|
Student Information Student Name: _________________________________________________ D.O.B. __________________ School: ___________________________ Grade:____________ Teacher: ______________________________ List Any Known drug allergies/reactions: ________________________________________________________ Height: ____________________ Weight: _______________________ |
|
Physician - Prescriber Order/Authorization Provider Name: __________________________________________ Office phone #:_____________________ Office Address:_____________________________________________________________________________ Medication Name: ________________________________________ Reason: _____________________ Dosage/Route: _______________________ Frequency: ___________________ Begin Medication: _____________________ Stop Medication: ______________ Potential Side Effects/Contradictions/Reactions: ____________________________________ When will the student be reevaluated? ____________________________________________
Special Instructions: Does the medication require refrigeration? Yes No Is the medication a controlled substance? Yes No
_________________________ __________ __________________ Physician Signature Date Fax # |
|
PARENT/GUARDIAN AUTHORIZATION As a parent/guardian I request the designated school personnel to administer the above medication at school according to district policy. Information regarding my child’s medication may be shared with appropriate school personnel. I authorize the school nurse to communicate with the health care provider.
________________________________________________ _________________________ Parent/Guardian Signature Date ______________________ _______________________ _________________________ Home Phone # Cell # Work # |
5/14
Adopted: February 28, 2018
Policy Revised: August 18, 2021