Williamson County Schools

AUTHORIZATION TO ASSIST COMPETENT STUDENTS

WITH SELF-ADMINISTRATION OF MEDICATION

Dear Parent(s),

The self-administration of prescription medication by students can only be done if you understand the information below, provide = your physician’s authorization, and your written consent. Thank you for your cooperation.

1= . = &nb= sp; Prescription medication can only be self-administer= ed at school when it is required to maintain the health

of the student.

2. &n= bsp; Medication must be brought to school by parent/guardian, for the student for whom it w= as prescribed. It

= must be in the original container, exactly matching the physician’s order, and labeled by the pharmacy to

= include the following:

&nbs= p; &= nbsp; &nbs= p; a. Name of student

&nbs= p; &= nbsp; &nbs= p; b. Name of physician

&nbs= p; &= nbsp; &nbs= p; c. Name of medicine

&nbs= p; &= nbsp; &nbs= p; d. Instructions as to dosage, amounts, exact time, and route.

3. &n= bsp; No more than a week supply should be brought to school. A student is allowed to carry a me= tered

&nbs= p; dose inhaler with them to have it readily accessible for self administration.

4. &= nbsp; The first dose of medication will be given at home in case of an adverse reacti= on to the medication.

_________________________ _____________ _______ &nbs= p; _____________ ___________________

= Student’s Name = &nb= sp; School = ; Grade Date of Birth = Medication Allergies =

___________________________ = __________________ = To be administered at ____________<= /o:p>

Name of Medication = &nb= sp; Dosage and Route &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; Time

PARENT/GUARDI= AN PERMISSION:

I acknowledge that the above named student is competent to self administer th= is medication with the assistance from the nurse or designated school employee while in attendance at school. I give permission for my child to self-administer this medication with the supervision of a designated school employee. I grant the school nurse permission= as necessary to discuss the pres= cribed medication with the below named physician. I agree to hold Williamson County Board of Education harmless for the administration of such medication. I give permission for my health care provider and Williamson County Schools to send or receive a fax of this medical record.

________________________________ = &nb= sp; ________________ = ___________________

Name of parent/guardian = &nb= sp; = &nb= sp; Home # = = &nb= sp; Work #

______________________= ________________ = &nb= sp; = ______________

= Signature of parent or guardian = &nb= sp; = &nb= sp; = Date

********= ***************************************************************************=

REQUIRED FOR PRESCRIPTION MEDICATIONS ADMINISTERED MORE THAN ONE WEEK <= /h1>
PHYSICIAN’S AUTHORIZATION FOR SELF ADMINISTRATIO= N&nbs= p; (To be completed by physician)

The above named student is under my medical supervisio= n.

Reason for medication to be administered at school:_____

Possible reactions/side effects:<= /p>
Special instructions for storage/handling:= _

Child may carry Inhaler on self or in book bag

Name of Physician: Date prescription expires=

_= ____________        =       _        =       __

        =           Signature of Physician        =             &nb= sp;            =             &nb= sp;      Title        =             &nb= sp;            =        Date

_= __________             =    _

        =             &nb= sp;          Address        =             &nb= sp;            =             &nb= sp;             Phone #        =             &nb= sp;             Fax #

Revised 04-03=         =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =      Form #2