Laurel Springs School

Medication Administration Permission

2011-2012

Please complete a separate form for EACH medication.

Date:                ___________________________                              Grade:  ___________

Child’s name:    ___________________________

Medication:      ____________________________________________________________

                        Prescription:  ___                                                         Non-prescription:  ___

Dosage:            _________________________________                  Route:  ____________

Time to be given (or special circumstances under which medication shall be administered):

_________________________________________________________________________

Diagnosis:         _____________________________________________________________

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 the School Nurse during the school year 2011-2012.  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:  856-783-1086 x112

                                                                                    Fax:      856-784-0474