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JLCD-R (PROCEDURE) - CESD REQUEST/PERMISSION TO ADMINISTER MEDICATION IN SCHOOL For Parent/Guardian

For Parent/Guardian

Date: _____________________
Student Name: __________________________
Grade/Teacher: _______________________
Medication: ___________________________
Pharmacy: ____________________________
Prescribing health care provider: ___________________
Phone number: _________________

**Y/N **Please administer this medication to my child on early dismissal days.

**Y/N **Please administer this medication to my child on field trip days.

At the end of the school year, last day of student’s enrollment, or date medication expires, I choose the following method of medication disposal:

CHOOSE ONE:

  • Parent will remove medication from school.

  • Send the medication home with my child.

  • School nurse may dispose of the medication.

I give permission for this medication to be administered by the school nurse or trained unlicensed assistive personnel designated by the principal as allowed by law. I further give permission for the school nurse to contact the prescribing health care provider to share information related to this medication, the medication administration schedule, and/or and effects of this medication on my child’s learning.

__________________________________ _________ / _____________ / ____________

Parent/Guardian Signature Telephone H/W/Cell

For the Prescribing Health care Provider

Medication/Dosage: _______________________
Time(s) to be administered: _______________

Reason for medication: __________________________________________________________

Possible side effects and safety procedures: __________________________________________

Health care provider signature is required for any prescription or over the counter medication. A prescription medication label may be used in lieu of a written order if the medication is to be given for 15 consecutive days or less. The school nurse will obtain the health care provider signature as needed. I give permission for this medication to be administered by the school nurse or trained unlicensed assistive personnel designated by the principal as allowed by law.

Provider signature: _______________________________
Telephone: ____________________

Date: ____________________________ Fax: ______________________

High School Health Office Phone: (207)799-3309 x 420 High School Fax: (207)767-8050

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