School Medication Authorization Form; Self-Administration Of Emergency Medications Template printable pdf download

School Medication Authorization Form; Self-Administration Of Emergency Medications Template

THIS SIDE TO BE COMPLETED IF MEDICATIONS FROM HOME ARE TO

BE GIVEN AT SCHOOL (Rx and OTC)

Centralia High School District 200

School Medication Authorization Form

Name of Student__________________________Date of Birth____________Grade_____

Name of

Parent__________________________________________________________________

Address_________________________________________Phone #_________________

Physician’s Name_________________________________Phone #__________________

Physician’s

Address_________________________________________________________________

Name of Medication__________________________Dosage of Medication___________

Directions for Use_________________________________________________________

Reason for Medication (Indicate type of illness)_________________________________

Other Medication(s) student is receiving at

home__________________________________________________________________________

__________________________________________________________________________

Possible Side Effects of Medication(s)_________________________________________

The approximate length of time that the student will receive this medication

is:______________________________________________________________________

X________________________________________________Date_________________

Parent Signature

X________________________________________________Date__________________

Physician Signature

Note to Physician and Parent: If medication is an inhaler or an EpiPen®, and it is medically

necessary for the student to carry the inhaler or EpiPen® with him/her at all times during school

hours, please complete and sign the Self Administration of Emergency Medications form on the

reverse side.

Please complete the reverse side if the student will need to carry an inhaler of EpiPen while at school.

School Medication Authorization Form; Self-Administration Of Emergency Medications Template