Microsoft word - authorizationmedication.doc

SKOKIE SCHOOL DISTRICT 73½
2009-10 AUTHORIZATION TO ADMINISTER MEDICATION
TO BE COMPLETED BY STUDENT'S PHYSICIAN

School District 73½ policy states that medications, including over-the counter medications, may be administered to students only upon
written request of the student's physician and parent. All medications must be brought to the nurse's office in the original container or
one properly labeled by the pharmacy or physician. The label must include the student's name, physician, name of medication, dosage
and time to be given. The nurse must be notified in writing of any changes. This form must be completed and returned to the health
office before any medication can be administered by district staff. The school district retains the discretion to reject requests for
administration of medication.
It is understood that this form constitutes a waiver to the school staff for liability for untoward reactions when the medication is
administered in accordance with the physician's directions. It is also understood that in the registered nurse's or health clerk's absence,
self-administration, under supervision by the principal's designee, may be necessary.


My child may require medication which must be taken during school hours. I authorize the school to supervise the administration of this
medication in the dosage and the time listed. I have read the above paragraph and consent to the school medication policy.

Please note that non-prescription medication, including pain relievers such as Tylenol, Advil, Dramamine and any over-the
counter medications, will not be administered by the school without a parent signature AND physician authorization.
Name of Student__________________________________________________________________________________
Date of Birth___________________ Grade 2009-10 _______
Name of Medication__________________________ Name of Medication___________________________________ Dosage and Time:___________________________ Dosage and Time:____________________________________ Duration of Administration:_____________________ Duration of Administration:______________________________ Reason for Medication:________________________ Reason for Medication:_________________________________ Must this medication be administered during school Must this medication be administered during school in order to allow student to attend?  YES  NO in order to allow student to attend?  YES  NO Are there any side effects to the medication? Are there any side effects to the medication?  YES  NO If yes, please explain__________  YES  NO If yes, please explain___________________ ________________________________________ __________________________________________________ Other medication student is receiving but is not administered at school?___________________________________________ Asthma or Allergy Medication Only – e.g. Inhaler, Epipen. 2. Student may self-administer medication *(We recommend that “back up” medication be stored in the Nurse’s Office as well.) Directions for self-administration_____________________________________________________________ _______ ______ _______ ______ _______ ______ _______ ______ _______ ______ _______ _____ Please affix office stamp here. (required) ________________________________________
Physician's Name (Please print)
_________________________________________ Physician's Signature (required)

Source: http://www.skokie735.k12.il.us/forms/0910MEDICATION.pdf