Adopted: February 1990
Revised: May 2015
Name of child
School School year
Physician’s Order for Student and Self-medication
Name of medication
Medical Condition/ICD-10 code
Possible side effects
Estimated termination date
The student is knowledgeable about the medication noted above and how to self-administer the medication.
As authorized by my child’s physician, I request that my child be allowed to carry and self-administer the prescribed medication noted above. I understand my child must carry this medication at all times in school or he/she will lose the right to carry and
self-administer the medication at school.
Signature Date parent or guardian