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