STUDENT INFORMATION

Student’s Name __________________________________ School Year_______________

School: Elba Elementary School Grade ___________ Teacher___________________

List any known drug allergies / reactions _______________________________________

Height ________________ Weight ____________________

PRESCRIBER AUTHORIZATION

Name of Medication _________________________ Reason for Taking (Optional) ____________________

Dosage ____________________ Route _____________________ Frequency / time to be given __________

Begin Medication ___________________________ Stop Medication ________________________________

Date Date

Special Instructions:

Does medication require refrigeration? Yes_________ No __________

Is the mediation a controlled substance? Yes _________ No _________

Is self-mediation permitted and recommended for the student? Yes ________ No ___________

If asthma inhaler or emergency mediation, do you recommend this medication be kept “on person” by the student? Yes ___________ No __________

Potential Side Effects / Contraindications/ Adverse Reactions __________________________________________

___________________________________________________________________________________________

____________________________________________________________________________________________

Treatment Order in the event of an adverse reaction: (Attach additional sheet or use the back of this form if necessary)___________________________________________________________________________________

___________________________________________________________________________________________

__________________________ ____________ __________________ _______________________

Signature of Prescriber Date Phone Fax

Parent authorization

I authorize the School Nurse, the registered nurse (RN) or licensed practical nurse (LPN) to delegate to unlicensed school personnel the task of assisting my child in taking the above medications. I understand that additional parent / prescriber signed statements will be necessary if the dosage of medication is changed. I also authorize the School Nurse to talk with the prescriber or pharmacist should a question come up about the medication.

Medication must be registered with the principal, his / her designee, or the school nurse. It must be in the original container and be properly labeled with the student’s name, prescriber’s name, date of prescription, name of medication, dosage, strength, time interval, route of administration, and the date of drug’s expiration when appropriate.

____________________________ _______________________ _________________

Signature of Parent or Guardian Date Phone

I authorize and recommend self-medication by my child for the above medication.

_______________________________________ ________________________

Signature of Parent or Guardian Date

If any questions pr problems arise, call me at ______________________ (Home)

__________________________ (Work) ________________________ (Cell)