STEWART COUNTY SCHOOL SYSTEM

Medication Authorization

 

Student:___________________________________________________D.O.B.____________

School:                                                                        Grade:             Teacher:

The medication policy of the Stewart County School System states:  medications shall be administered only when the student’s health requires that they be given during school hours.  Medication must be brought to the school by a responsible adult.   (Prescription medication must have a proper pharmacy label attached.  Non-prescription medication must be in a new unopened container.)  All medications shall be kept in a locked cabinet (*inhalers may be kept with student if noted by physician below).

 

TO BE COMPLETED BY THE PHYSICIAN OR AUTHORIZED PRESCRIBER

(If non-prescription medication, parent must fill out)

 

 

Name of medication:                                                           Reason for medication:______________________

 

Form of medication/treatment:

ð Tablet/capsule      ð Liquid     ð Inhaler     ð Injection     ð Nebulizer     ð G-Tube     ð Other _____________

 

Schedule [Time(s) of administration]: __________________________             Dosage: ________________

Start: ð date form received               (Office use only:  Date received: __________)

Stop:  ð end of school year               Other date / duration: _________________

           ð For episodic / emergency events only

 

Restrictions and / or important side effects:    ð  None anticipated           ð Yes

 If yes, Please describe:  ___________________________________________________

 

Special storage requirements:   ð  None      ð  Refrigerate               ð  Other: ______________

 

This student is both capable and responsible for assisted self-administration of this medication:

ð No ( a nurse must administer)   ð  Yes-Supervised ( a trained teacher/principal/assistant may administer)

ð Student may carry this medication  (Emergency medications only)

 

 

Date: ____________________                      Physician signature: ________________________

Physician’s Name:                                                     Phone Number:

Address:

 

 

 

 

TO BE COMPLETED BY PARENT / GUARDIAN

I give permission for my child to receive the above medication during the school day assisted by school personnel as necessary.  My child is both capable and responsible to self-administer this medication with assistance.  

1  Yes     1   No  Please report concerns about medications or disease to the above physician and myself.

 

Date: _______________  Parent Signature: ___________________________________

Phone numbers (in case of emergency) ____________________________________________________________

Total completion of this form is mandatory.