PERMISSION FOR ADMINISTRATION OF MEDICINE - LINK TO JGFGB

USD 443 – DODGE CITY PUBLIC SCHOOLS
PERMISSION FOR ADMINISTRATION OF MEDICATION  
(Revised June 2015)

Permission for Administration of Medication - Printable Version

Name of Student _______________________________________________________________________________________

Grade___________________________    Building ________________________________________________

Teacher ___________________________________________________________________________________________

Diagnosis__________________________________________________________________________________

Medication__________________________________________________________________________________

Dosage ___________________________________________________________________________________________

Time(s) to be given____________________________  Duration of Orders ______________________________

*USD 443 will require a current medical authorization from the medical provider at the start of each new school year.  School Nurses reserve the right to request additional information from a physician.

If medication prescribed is for EpiPen, Rescue Inhaler, and/or Diabetic Management – student has demonstrated to health care provider/designee skill level necessary to self-administer               Yes    No 

Date _____________ Signature of Physician ____________________________________________________

Office Address ____________________________________________________________________________

Office Telephone Number ____________________________________________________________________

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I  hereby  give  my  permission  for to  take  the  above prescribed medication at school as ordered.  I understand that it is my responsibility to furnish this medication.  I further understand that any school employee who administers any medication to my student in accordance with written instructions from the physician or dentist shall not be liable for damages as a result of an adverse reaction suffered by the student because of administering such medication.  I am requesting the cooperation of school personnel in this matter. 

Date ___________________ Signature of Parent or Guardian ___________________________________________________________

NOTE TO PARENT/GUARDIAN:   The medication is to be brought to school in the original container appropriately labeled by the pharmacy or physician stating the name of the medication, the dosage, and time to be administered.  It is suggested that medication be administered outside of the school day whenever possible.