5420E-2
5420E-2
STUDENT HEALTH SERVICES EXHIBIT
Permission for the Use of Medications
The district strongly recommends that whenever possible, all medications. even non-prescription, be kept by the school nurse/teacher. However, students may carry medications and self administer only if the following conditions have been satisfied:
1. the following form is completed;
2. you have educated your daughter/son in regard to responsible usage of this medication;
3. the student is found to be responsible by school officials;
4. only a one day supply is carned, except for inhalers; and
5. if irresponsible use is noted, privilege will be rescinded.
………………………………………………………………………………………………………
Child’s Name Birthdate Today’s Date Medication Allergies
NON-PRESCRIPTION MEDICATION PRESCRIPTION MEDICATION
1. Medication 1. Medication
Dosage Dosage
Time to be given Time to be given
Reason to be given Reason to be given
Comments Comments
___Student appears mature and responsible and self-medication is part of a therapeutic plan.
Student was instructed in proper use and will carry and self-administer medicine.
__Please have school nurse store and administer medication.
…………………………………………….
Signature Of Parent/Date/Telephone #
Signature Of Parent/Date/Telephone #
………………………………………….
Signature of Physician/Date/Telephone#
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Adoption date: January 29. 1997