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    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)