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.                    Prescription medication can only be self-administered at school when it is required to maintain the health

of the student.

2.             Medication must be brought to school by parent/guardian, for the student for whom it was prescribed.  It

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

              include the following:

                                a.  Name of student

                                b.  Name of physician

                                c.  Name of medicine

                                d.  Instructions as to dosage, amounts, exact time, and route.

3.             No more than a week supply should be brought to school.  A student is allowed to carry a metered

                dose inhaler with them to have it readily accessible for self administration.

4.             The first dose of medication will be given at home in case of an adverse reaction to the medication.

_________________________        _____________    _______      _____________         ___________________

           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

***********************************************************************************

REQUIRED FOR PRESCRIPTION MEDICATIONS ADMINISTERED MORE THAN ONE WEEK

PHYSICIAN’S AUTHORIZATION FOR SELF ADMINISTRATION  (To be completed by physician)

The above named student is under my medical supervision.

Reason for medication to be administered at school:_________________________________________________

Possible reactions/side effects:__________________________________________________________________

Special instructions for storage/handling:_________________________________________________________

Child may carry Inhaler on self or in book bag ____________________________________________________

Name of Physician:______________________________________  Date prescription expires______________

_________________________________________              ___________________              ________________

                  Signature of Physician                                                    Title                                        Date

_______________________________________________     __________________           _________________

                               Address                                                           Phone  #                                  Fax #

Revised 04-03                                                                                                                                                                   Form #2