ROCKINGHAM COUNTY SCHOOLS

PERMISSION TO ADMINISTER MEDICATION

This form gives permission to authorized members at your child’s school, to administer medication to your child. This form must be completed and signed by both the parent and the child’s physician. The medication must be in a prescription bottle with the original label attached.

Student’s Name__________________________________________Age_______Grade______

School Name_____________________________________Teacher____________________

Physician’s Name (Printed)_____________________________________________________________________

Physician’s office #___________________Physician’s fax#_____________________

Medication Prescribed______________________________________Dosage________________

Time to be given at school________________________________________________

Purpose of medication____________________________________________________________

Possible side effects________________________________________________________________

This student has my permission to carry and self administer an INHALER or EPI-PEN. YES NO

This student has my permission to self administer INSULIN. YES NO

Physician’s signature____________________________________________Date_______________

I hereby release the Board of Education, their agents, and employees from any and all liability that may result from my child taking this medication. I also give the school nurse permission to contact the prescribing physician in order to insure the safe administration of this medication.

Parent’s signature_______________________________________________Date____________

NOTE

This permission form is valid for the ___________________ school year only. This permission form and a log of the medication administered to your child indicating the date, time given and the initials of the authorized staff member administering the medication, will be kept on file at the school. If your child’s medication, dosage, or physician changes during the school year, a new permission form must be completed.

Reviewed by School Nurse____________________________________________Date_________________

Teaching All Students to Become Productive Citizens and Lifelong Learners