Authorization for Administration of Medication

 

  1. To be completed by the parent or guardian:

I request that my child______________________________grade_______receive the medication as prescribed below by our licensed health care provider.  The medication is to be furnished by me in the properly labeled original container from the pharmacy.  I understand than the school nurse, or other designated person in the case of the absence of the school nurse, will administer the medication. 

 

__________________________________________________

(Signature of Parent/Guardian)

 

Address:___________________________________________________________________

 

Ph. Home _________ Work _________ Cell __________ Date:__________________

 

       B.  To be completed by the licensed health care provider  

 

I request that my patient, as listed below, receive the following medication:

 

Name:_______________________________________ Date of Birth:_____________

 

Diagnosis:_____________________________________________________________________

 

Medication:_____________________________________________________________

 

Prescribed  Frequency and Route of Administration:______________________________

 

Time During School Hours:_____________________________________________

Duration of Treatment: _______________________________________________

Side Effects  Adverse Reactions (if any):___________________________________

 

Other:_________________________________________________________

 

Name Licensed Provider and Title (please print):___________________________________

 

Prescriber:

Signature:____________________________________________ Date:_____________________

 

Address:_____________________________________________Phone:____________________

                                                                                                                                     

 

Cattaraugus-Little Valley Intermediate School

207 Rock City Street

Little Valley New York 14755                   Tele. 938-9155                     Fax. 938-6576

 

Self-Medication Release Form

 

For Inhalers

 

Date:___________________________

 

Child’s Name:________________________________ has been instructed in the proper

 

use of the inhaler (name of)________________________________________________.

 

We,  (Physician’s name) __________________________________________________

 

and (Parent/Guardian’s name) ______________________________________________

 

request that (Child’s name)_________________________________________________

be permitted to carry the inhaler on his/her person or to keep the same in his/her locker or P. E. Locker, as we consider him/her responsible.  He/she has been instructed in and understands the purpose and appropriate method and frequency of use of his/her inhaler.

 

 

 

 

 

 

We, the undersigned, absolve the school of any responsibility in safeguard in our child’s use of the inhaler.

 

________________________________________________________________________

Physician

________________________________________________________________________

Parent/Guardian

 

 

 

 

 

 

Note:  The attached from must be completed in addition to the routine district medication form for those students who request permission to carry their own inhaler on campus or keep this inhaler in Physical Ed Locker.  

                                                                                                                       

(see reverse)