DISPENSING MEDICATION AT SCHOOL
Church of the Assumption School

School policy requires of the parent/legal guardian and a written statement (order) from the licensed prescriber before medication can be given to a student by school personnel.  The following is necessary in order to comply with this policy.  All requested information must be completed in full.  Please return the completed form to the school office. 

Name of Student:_______________    Grade____________  Homeroom________
Date of Birth ______________

TO BE COMPLETED BY THE STUDENT'S LICENSED PRESCRIBER.( PHYSICIAN)

The above mentioned student is under my care for (diagnosis) __________________________
______________________________________________________________________________

Name of Medication:_____________________________________________________________ 
Dosage and Route: ______________________________________________________________
Dosage times: ________________________________________________________________
Duration of dosage: _____________________________________________________________ 
Specific instruction for administration:____________________________________________
Possible Side Effects: ___________________________________________________________ 

Physician: ____________________________ Telephone Number: ________________________ 

Physician's Signature ___________________________________________________________ 

MEDICATION MUST COME TO SCHOOL IN THE ORIGINAL CONTAINER WITH THE AFIXED LABEL FROM THE PHARMACIST.  THE LABEL MUST SHOW THE STUDENT'S NAME, THE NAME OF THE MEDICATION, THE DOSAGE DIRECTIONS, THE LICENSED PRESCRIBER'S NAME AND THE RX NUMBER (IF THERE IS ONE).

TO BE COMPLETED BY PARENT/GUARDIAN 

I give my permission for the principal or his/her designeee to administer the prescribed medication as prescribed above to my child and further agree to the following:
1. Submit to school personnel a revised statement signed by the licensed prescriber of the above medication when any change in original statement (order) occurs.
2. Submit to school personnel a written statement when medication, given on a daily or as needed basis, has been discontinued.
3. Grant permission for the school nurse to confer with the above licensed prescriber regarding my child's health and treatment issues as they pertain to the above medication/diagnosis and his/her educational and behavioral management needs.
4. Cooperate with school personnel in assisting my child to comply with medication administration instructions.
5.  Provide safe transportation of the medication to and from school. 

Signature of parent/guardian:_____________________________ Date signed: _________

THIS PERMISSION IS NO LONGER VALID AT THE END OF THE CURRENT SCHOOL YEAR.