Medication Administration Forms
REQUEST FOR NURSE
TO ADMINISTER MEDICATION AT SCHOOL |
If your child requires a daily medication that is a prescription, please fill out the top portion of this form AND have the child's prescribing physician sign. Then return to the school nurse. If you would like to leave an over the counter medication (ie: Tylenol, Motrin, Cough Drops) to be administered on an as needed basis, please fill out the bottom portion of this form and return to school nurse.
**ALL medications, either prescription or over the counter, must be in their original bottle/box/bag. If it is a prescription medication, it MUST have a current prescription label with your child's name attached to the medication.**
**ALL medications, either prescription or over the counter, must be in their original bottle/box/bag. If it is a prescription medication, it MUST have a current prescription label with your child's name attached to the medication.**
ASTHMA ACTION PLAN
If your child has been diagnosed with Asthma, and requires a rescue inhaler any time during the year, please have the Asthma Action plan filled out and signed by the child's physician
**ALL medication must be in it's original bottle/box and have a current prescription label with your child's name on it**
If your child has been diagnosed with Asthma, and requires a rescue inhaler any time during the year, please have the Asthma Action plan filled out and signed by the child's physician
**ALL medication must be in it's original bottle/box and have a current prescription label with your child's name on it**
INHALER SELF CARRY PERMISSION
If your child has been diagnosed with Asthma, and requires a rescue inhaler any time during the year, and you and the child's physician feel that the child is capable of carrying his/her own inhaler, please ensure the Physician checks the "self carry" box on the bottom of this form
**ALL medication must be in it's original bottle/box and have a current prescription label with your child's name on it**
If your child has been diagnosed with Asthma, and requires a rescue inhaler any time during the year, and you and the child's physician feel that the child is capable of carrying his/her own inhaler, please ensure the Physician checks the "self carry" box on the bottom of this form
**ALL medication must be in it's original bottle/box and have a current prescription label with your child's name on it**
ANAPHYLAXIS ACTION PLAN
If your child has severe allergies that require an available Epi-Pen and/or Benadryl please have allergy_and_anaphylaxis_policy
filled out and signed by the child's physician and return it to the school nurse
**ALL medication must be in it's original bottle/box and have a current prescription label with your child's name on it**
If your child has severe allergies that require an available Epi-Pen and/or Benadryl please have allergy_and_anaphylaxis_policy
filled out and signed by the child's physician and return it to the school nurse
**ALL medication must be in it's original bottle/box and have a current prescription label with your child's name on it**