Permission Form for School to Administer Medication
by Katie Kettler
January 15, 2007
USD 415
HIAWATHA SCHOOL DISTRICT
PERMISSION FOR MEDICATION
(REQUESTING AUTHORIZED STAFF TO ADMINISTER MEDICATION TO STUDENT)
Name of Student _________________________________________ DOB ______________
School____________________________________________ Grade ___________________
Teacher (s) _________________________________________________________________
Medication________________________________________ Dosage ___________________
Date Medication Starts at School ___________ Diagnosis/Reason For Med ______________
_________ (Please Check if Yes) Initial dose was given at home with no adverse reactions.
Time of day medication is to be given at school ___________________________________
Expected Duration of Medication ________________________________________________
_____________________ _____________________________________
DATE PHYSICIAN'S SIGNATURE
______________________________________
PHYSICIAN'S NAME (PRINTED)
*******************************************************************************
I hereby give my permission for _____________________________________ to take the above prescription at school as ordered. I verify that my student has previously had at least one dose of the above-prescribed medication and did not have an adverse reaction from it. I understand that it is my responsibility to furnish this medication. I further understand that any school employee who administers any drug to my student in accordance with written instructions from the physician or dentist shall not be liable for damages as a result of administering such drug or because of mislabeled or altered products. I hereby authorize USD #415 personnel to exchange information regarding this request with the above-named attending physician and with the pharmacy as identified on the affixed pharmacy label.
DATE: _________________________ __________________________________________
Signature of Parent or Guardian
NOTE: The medication is to be brought to school in the original container appropriately labeled by the pharmacy or physician stating the name of the medication, the dosage, and times to be administered.
