Over the counter (Non-Prescription) “As Needed”

Williamson County Schools

AUTHORIZATION TO ASSIST COMPETENT STUDENTS

WITH SELF-ADMINISTRATION OF MEDICATION

Dear Parent(s),

The self administration or assisted administration of non-prescription/over the counter medication may be done at school following these guidelines:

1.        Parent or legal guardian must complete this authorization form.  All medication (this includes topicals as well

as cough drops, Tylenol, or Motrin) must be brought to the office by the parent. 

STUDENTS ARE NOT ALLOWED TO BRING THEIR OWN MEDICATION TO SCHOOL.

2.        The medication must be in the manufacturer’s original bottle, sealed, with the student’s name on the

bottle/box.  No open containers will be accepted.

                3.    No medication can be given after the expiration date.

_________________________        _____________    _______      _____________         ___________________

           Student’s Name                          School             Grade         Date of Birth            Medication Allergies            

___________________________          __________________               To be  administered at ____________

         Name of Medication                       Dosage and Route                                                               Time

PARENT/GUARDIAN PERMISSION:

I acknowledge that the above named student is competent to self administer this 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 prescribed 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.

________________________________                           ________________                     ___________________

        Name of parent/guardian                                                 Home #                                          Work #

______________________________________                                      ______________

             Signature of parent or guardian                                                                   Date

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 Form #5