PARENT AND PHYSICIAN'S AUTHORIZATION FOR ADMINISTRATION OF 
MEDICATION IN SCHOOL AND SCHOOL ACTIVITIES

A.  To be completed by the parent or guardian:

I request that my child _____________________________DOB ____________ receive the medication as prescribed below by our physician. The medication is to be furnished by me in the properly labeled original container from the pharmacy*. 
PLEASE CHECK ONE:
1	I understand that the school nurse, or other designated person in the case of the absence of the school nurse, will administer the medication, including field trips to my self directed child
1	I understand that administration of oral, topical or inhalant medications to my non self-directed child and injectable medications must remain the responsibility of the school nurse, licensed practical nurse under the direction of a school nurse, physician, or parent.

Signature(Parent or Guardian):   ________________________________________________                                                                                             

Telephone:  Home                                      Work                                     Date _____________
                     
B.  To be completed by physician:

I request that my patient, as listed below, receive the following medication:

Name of Student                                                                         DOB ____________________                                     
	
Diagnosis:  _________________________________________________________________      
                                                                                                                         
Medication	Dosage	frequency/Time to be taken	route of administration	

				

Duration of Treatment:                                                                                                             

Possible Side Effects and Adverse Reactions (if any):                                                            

Physician's Signature                                                               Date:______________________                                       

Address:                                                                                  Phone:_____________________ 

*  	Medication must be in original pharmacy labeled container with specific orders and name of 	medication.
*	Medication and refills must be brought to school by parent, guardian or responsible adult.

Plan reviewed with parent(s)/guardian(s):

	Parent Signature:_________________________________Date:_______________________