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Microsoft word - medicationform

Medication Administration Form
To be completed and signed each year by physician/designee and parent for non-prescription and prescription medications.
Absolutely no medications (non-prescription, over the counter or prescription) will be administered by either school personnel or self (student) without the written authorization of a physician/designee and parent. Dosage and route for a medication will be administered according to manufacturer’s recommendations on the label unless otherwise indicated by physician. Generic substitutions may be used for non-prescription medications listed. Submit a new form during the school year if there are changes or additions. This form is also the authorized form used for off-campus activities, including overnight trips.
TO BE COMPLETED AND SIGNED BY PHYSICIAN/DESIGNEE AND PARENT/GUARDIAN:
Child's name_____________________________________________________________________________Grade 2014-2015______
Drug Allergies (if none, state none)_______________________________________________________________________________ NON-PRESCRIPTION MEDICATIONS IN CLINIC:
All of the Medications Above
PRESCRIPTION MEDICATIONS
Please list any prescription medications to be administered during the school day, including overnight field trips. _____________________________________________ ______________ _____________________ ______________________ Possible side effects: _____________________________________________ Order in effect until (date):_________ _____________________________________________ ______________ _____________________ ______________________ Name of medication Dosage Possible side effects: _____________________________________________ Order in effect until (date):_________ _____________________________________________ ______________ _____________________ ______________________ Possible side effects: _____________________________________________ Order in effect until (date):_________

For Epi Pens, Inhalers for asthma, Glucagon and Insulin ONLY.
All other medications must be administered by the school nurse or designee.
This student is both capable and responsible for self-administering this medication: NO ____ YES- Unsupervised ___
This student may carry this medication: NO ____ YES ____

Physician/Nurse Practitioner/Physician Asst.Signature: _______________________________________ Date: _______________ Physician Address/Phone Number: _____________________________________________________________________________ I request my child be administered the prescription/non-prescription medications as indicated in the physician's order above. Parent/Guardian Signature: _____________________________________________________________ Date: _______________ TO BE COMPLETED BY THE SCHOOL: Date Received_________________ School Nurse _______________________________________
Greensboro Day School, 5401 Lawndale Drive, Greensboro, NC 27455 • 336.288.8590 • FAX: 336.282.2905 • www.greensboroday.org

Source: http://www.greensboroday.org/uploaded/documents/Health_Room/Medicationform.pdf

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