4255-6135.A-Request for Medication To Be Completed By the Physician

Student Name:_____School:_____

Medication: ______Dosage: _____ (No injection will be given except in extreme emergency.)

Time(s) medication is to be given: a.m. __ p.m. To be given from __ to _ (Pre K limited to six months) ## Note: To Be Completed For Self Administered Asthma/Anaphylactic Medications This student will be self administering medication and has demonstrated the skill level and knowledge to do so (Physician initial) ___

Significant Information (including side effects, toxic reactions, omission reactions):______ ___________________

Contraindications for Administration: ___________ ________________ ____________________

EMERGENCY ACTION PLAN (Must be completed for all ASTHMA/ANAPHYLACTIC Medications.) If symptoms of _______occur during the school day or if the student becomes ill, school officials are to implement the following: a. Contact the physician at my office____ Telephone ___ b. Contact parent at _______ c. Call 911 have child taken immediately to the nearest emergency room. d. Other option ___________

This medication will be furnished by parent or guardian within a container properly labeled by a pharmacist with identifying information, (e.g., name of the child, medication dispensed, dosage prescribed, and the time it is to be given.) Expiration date required for Pre K. OTC medications must be in the original container with the same information.

____ DEA# ___ Date ____ Physician’s Signature

Parent’S Permission

  1. I hereby give my permission for my child (named above) to receive medication during school hours. A licensed physician has prescribed this medication. I hereby release the Avery County Board of Education and their agents and employees from all liability that may result from my child taking the prescribed medication or from any injury arising from my child’s possession and self-administration of prescribed medication.

______ ___ Parent or Guardian’s Signature Date

(School Use Only) Name and title of person to administer medication __________

Approved by _____ ___ Principal’s Signature Date

Reviewed by _____ ___ School Nurse’s Signature Date