WAYNE COUNTY SCHOOLS

REQUEST FOR MEDICATION AT SCHOOL

(Prescription and Non-prescription)

Student’s Name School___________________

Birth date Grade____ Parent’s name ______________________

TO BE COMPLETED BY PHYSICIAN:

Date of order_________________

Name of medication _____________________________ Dosage______________

Route of administration_____________ Frequency of administration__________________

Diagnosis_______________________________________________

Intended effect of medication_____________________ Discontinuation Date_______________

Other medication student is receiving___________________

Time interval for reevaluation_____________________

Possible adverse effects of this medication_____________________

Lay person may be trained to administer this medication_______________

Doctor’s SIGNATURE________________________

Telephone # ________________ Address________________________________

TO PARENT/GUARDIAN:

Medication must be brought to school in a container appropriately labeled by the pharmacy or physician; nonprescription medications ordered by a physician should be brought with the original label and the student’s name affixed to the container. Only those medications which are necessary to maintain the student in school or must be given during school hours shall be administered. If you have any questions, please call the school nurse.

The school district and its employees and agents are to incur no liability, except for willful and wanton misconduct, as a result of any injury arising from the self-administration of medication by the pupil.

I hereby authorize the above named school and its certified employees to act in my behalf to supervise the administration to by student (or supervise self-administration) the medication prescribed above. I acknowledge that a school nurse may not be available to supervise the administration and specifically consent to certificated school employees giving the medication instead of the school nurse.

Date____________ _________________________________

(Signature of parent/guardian)

Phone________________ Emergency/work phone # ___________________