Request for Medication to be Given During School Hour
Lincoln County Schools
P.O. Box 400, Lincolnton, NC 28093-0400
Request for Medication to be Given During School Hours
To be completed by physician
Name of Student_________________________ School______________________________________
Medication______________________________ Dosage/Route________________________________
(No injection will be given except in extreme emergency, such as allergy to bee stings)
Time(s) medication is to be given at school a.m. ____________________ p.m.___________________
To be given from (date)_______________________________to (date) ____________________________
Significant Information: (e.g., purpose of medication, side effects, any special instructions for giving meds at school, contraindications)
Would it be acceptable to keep the medication in the school’s main office?______________________________
This medication will be furnished by parent/ guardian within a container properly labeled by a pharmacist with identifying information, (e.g., name of the child, medication dispensed, dosage prescribed, and the time it is to be given). Over-the-counter medications will be in the original container labeled with the student’s full name.
Physician’s Signature___________________________________Date________________________________
Group Name_______________________Phone#_________________________Fax#_____________________
Physician is to complete this box ONLY if student is to carry and self medicate
with inhaler or epinephrine auto-injector.
I feel that it is medically necessary for the above named student to carry his/her own medication and self-medicate as prescribed. I have provided education to the student on indications for the use of the medication and methods of administration.
Physician’s Signature____________________________Date___________________________
******************************************************************************************
Parent’s Permission
I hereby give my permission for my child (named above) to receive medication during school hours. I understand that the school undertakes no responsibility for the administration of the medication. I also understand that this medication will be disposed of at the expiration date of this order. Medication orders are only good for the length of the school year. Please make every effort to pick up your child’s medication the last day of school. This medication has been prescribed by a licensed physician. I hereby release the School Board and their agents and employees from any and all liability that may result from my child taking the prescribed medication.
___________________________________________________
Signature of Parent/Guardian & Telephone Number
_________________________ _______________________ Expiration Date of Medicine Date
-----------------------
SCHOOL TO
PLACE
PHOTO
HERE IF AVAILABLE
Reviewed by School Nurse:
(signature/date
_____________________
_____________________
________
................
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