Authorization For Student Medication

AUTHORIZATION FOR STUDENT MEDICATION To the Principal of _________________________ School

Date___________________

I, the parent/guardian of ______________________, whose birth date is_____________, request that the following necessary medication be given to my child at school on a daily or on an emergency basis as needed. I release school personnel from any liability involved with administering this medication according to the doctor’s instructions below. _______________________________ Parent Signature

___________________________ Parent’s Printed Name

____________ Date

In accordance with the request of the parent above I request that the following medication be given to ___________________ by school personnel during regular school hours: Medication to be given 1. ___________________ 2. ___________________ 3. ___________________

Dosage _______ _______ _______

Time ______ ______ ______

Diagnosis _______________________ _______________________ _______________________

Does this medication require refrigeration?

Yes

No

Would this medication prevent the child from participation in any school activities?

Yes

No

Do you recommend that this medication be kept with the student at all times? (Only asthma inhalers, Epi Pens, and diabetic medications and supplies can be carried by a student at school)

Yes

No

Does this student need adult supervision to self-administer the medication which will be kept with him at all times? (such as inhalers, Epi Pens and diabetic medications)

Yes

No

Are there any potential side effects of these medications which the school staff should be aware of?

Yes

No

Are there any additional concerns or instructions regarding these medications?

________________________________________

Note: If a request is being made to give Glucagon to a diabetic student in an emergency low blood sugar situation, an additional, specific form, the Utah State Administration of Glucagon form, must be signed by the parent and physician and kept on file at the school. __________________________ Physician Signature

______________________ Physician’s Printed Name

_____________ Date

____________________ Signature of Principal

____________________ Signature of School Nurse

_____________ Date

_________ Date

Signature of staff members assigned to administer the above medications: 1.___________________________

2._________________________

Date

____________