School:_______________Phone #______________Fax # __________________

Date form received by the school:___________________________________________

Grade:_____________Teacher/Classroom:_____________________________________

· To be completed by the physician or authorized prescriber:

Reason for medication:__________________________________________________

Name of medication:____________________________________________________

Form of medication/treatment:____________________________________________

ڤTablet ÿ Liquid ÿ Inhaler ÿ Injection ÿ Nebulizer ÿ Other

· Instructions (Schedule and dose to be given at school):________________________

Start: ÿ Date form received Other date:___________________

Stop: ÿ End of school year Other date:___________________

ÿ For episodic/emergency events only

Restrictions and/or important side effects: ÿ None anticipated  Yes

Please describe:_______________________________________________

Special storage requirements: ÿ None ÿ Refrigerate 

Phone: ________________ Fax #:______________________________

· This student is both capable and responsible for self – administering this medication:

ÿ No ÿ Yes-Supervised ÿ Yes-Unsupervised

Physician’s Name: ___________________Signature: ___________________________

Address: ___________________________Phone number: _______________________ Fax # __________________________ 

· To be completed by the parent/guardian:

The district shall incur no liability as a result of any injury arising from your child

self-administering medication at school.

Date: _________________Signature of Parent: ______________________________

Please report concerns about medications or disease to the above physician.

· To be completed by the principal:

Date: __________ Name of school employee(s) designated by the principal or nurse to administer the medication________________________________

· To be completed by parent/guardian:

I give permission for (name of child)__________________________to receive the above medication at school according to standard school policy.

Medication must be brought to school in the original container

Date: _________Signature: ______________________ Relationship: ___________

Phone: _________________ Location: ___________________________