Permission Form for School to Administer Medication

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)

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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.