Parents of students requesting that medication be administered during school hours by the school Staff* are required
to provide for the school: 1 PHYSICIAN ORDER; PARENTAL RELEASE; 3 Medication supplied in the ORIGINAL BOTTLE. Ask for prescription
medication to be divided in two bottles completely labeled - one for home and one for school.
Student's Name_____________________________Birthdate:________
Home Address___________________________Grade:______
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PHYSICIAN'S ORDER FOR ADMINISTRATION OF MEDICATION BY SCHOOL PERSONNEL
I have prescribed the following medication for this student and request the dosages given during the school hours.
Medication name:_______________________________Dose_____________Time_________
For the treatment of:___________________________________________
Possible side effects:___________________________________________
If an inhaler, may this student carry it with him/her? YES
NO
Special Instructions:___________________________________
Last date to be given:_________________________________________
Physician's signature:_______________________________Date__________________
Print Physician's name, phone number, office address______________________________________________________
____________________________________________________________
.............................................................................................................
PARENTAL REQUEST FOR ADMINISTRATION OF MEDICATION: Only when a medication is prescribed to be taken during school hours
will a child be given medication at school. I request this medication be given as prescribed and the above requested information
be released to the physician from the school. If necessary, the school may request additional information from the physician
regarding illness.
Parents Signature:_____________________________________
Daytime phone________________Date_________
*Administration of medication will not neccessarily be done by a school nurse.
