LAUREL SPRINGS SCHOOL
Medication Administration Permission
2007-2008
Please complete a
separate form for EACH medication.
Date: ____________________
Child’s name:
___________________________________
Grade: _____
Medication:
_______________________________________________
Prescription: ___
Non-Prescription: ___
Dosage:
__________________________
Route: _______________
Time to be given (or special circumstances under which
the medication shall be administered): __________________________________________________________________________________
Diagnosis:
____________________________________________________ญญ__________________
May skip school-time dose on field trip: Yes____
No____
Possible side effects:
_______________________________________________________________
Prescription effective dates from: ________________
To: ______________
We give our permission for the above medication to be
administered by school personnel during the school year 2004-2005. It is my understanding that the School Nurse will
administer the medication as specified above. We
agree that we will not hold liable any member of the school staff or an individual of
official capacity who is directed by us (the parents/legal guardian) to assist our child
in taking the above medication. Any change to
the above will occur only with written instructions from the physician. All medication must be brought to school by the
parent/guardian in the original container with the pharmacy label. If needed, your pharmacy should provide you
with an extra labeled container. (No
envelopes or baggies please!). If the
medication is an over-the-counter medication, please label it clearly with the student’s
name.
Physician’s
Signature: _____________________________ Date: ____________
Parent’s Signature: _____________________________ Date: ____________
Linda
Garrett, RN
School
Nurse
Phone: 856-627-6068
Fax: 856-784-0474