Medication Order and Parent/Guardian Consent

Name of Student: ____________________DOB:_______YOG:___________

Name of Parent/Guardian:__________________________________________

Student Address:_________________________________________________

Home Phone:__________Work Phone:____________Cell Phone:__________

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Name of Presciber:______________________________Phone:____________

Address:________________________________________________________

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Medication:_____________________Dose:________________Route;________

Time Given at School:_____________________Start Date:___________End Date:__________

Diagnosis:_______________________________________Allergies:________________________

Other Medications taken by student*:___________________________________

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• I give my permission to have the nurse at school or school staff designated by the nurse, administer this student the medication on this order.
• I give permission for the nurse at school to share with appropriate school staff information relative to the prescribed medication. Yes_____No____
• I give permission for this student to self-administer medication if the nurse at school determines it is safe and appropriate. Yes___No_____
• I give designated school personnel permission to administer this medication on a field trip during this school year (not applicable for all medications). Yes____ No______
• I give permission for the nurse at school to share information with the prescriber about my child and this medication. Yes_____NO____

Parent/Guardian Signature:_______________________________Date:__________

Prescribing Provider Signature:___________________________Date:__________

*If not in violation of confidentiality