5420-E.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 carried, 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 if irresponsible use is noted, privilege will be rescinded.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 Student appears mature and responsible
and self-medication is part of a therapeutic and self-medication is part of a therapeutic
plan. Student was instructed in proper use plan. Student was instructed in proper use
and will carry and self-administer medicine. and will carry and self-administer medicine.
Please have school nurse store and Please have school nurse store and
administer medication. administer medication.

Signature of Parent/Date/Telephone # Signature of Physician/Date/Telephone#

Signature of Parent/Date/Telephone#