Adopted: December 1987
Revised: August 2024
Student ________________________________ DOB____________________ Grade ____________________ School Yr____________________
School__________________________________________________ Allergies____________________
NOTE: Medication must be supplied in original labeled prescription bottle.*No narcotic pain medication will be administered during the school day unless authorized by a authorized healthcare provider.
| Medication | Controlled Substance Yes/No | ICD-10Medical condition | Dose | Time | Route | Possible side effects |
| 1. | ||||||
| 2. | ||||||
| 3. |
other considerations/directions _________________________________________________ _____________________________ __________________________________ _______________
signature of authorized healthcare provider print name of authorized healthcare provider date
_____________________________ __________________________________ _______________
clinic name clinic phone clinic fax
Parent/Guardian Authorization
1. I request that the above medication(s) be given during school hours as ordered by my student’s authorized healthcare provider. I also request the medication(s) be given on field trips as prescribed.
2. I will notify the school of any change in the medication(s), i.e., dosage change, medication is stopped, etc.
3. I give permission for the medication(s) to be given by trained school personnel when delegated by the school nurse in her/his absence.
4. I release school personnel from liability in the event adverse reactions result from taking the medication.
5. This consent may be revoked at any time by sending a written notice to the licensed school nurse.
6. I understand that I am required to retrieve controlled substances when requested by the school.
7. I designate the school district as an authorized entity to transport non-controlled substances for purposes of destruction if unused amounts remain in the possession of school personnel.
___________________________________________________________________________________________________________________________________________ parent/guardian signature date relationship to student
Permission for Release of Information
1. I give permission for the school nurse to communicate, as needed, with school staff about my child’s medical condition(s) and the action of the medication(s).
2. I give permission for the school nurse to consult with my child’s authorized healthcare provider about any questions regarding the listed medication(s) or medical condition(s) being treated by medication(s).
3. I give permission for the authorized healthcare provider to release information related to the above medication(s) and medical condition(s) to the licensed school nurse.
___________________________________________________________________________________________________________________________________________ parent/guardian signature date relationship to student
Return to__________________________ phone _________________________fax _________________________
RN, Licensed School Nurse