ADMINISTRATION OF MEDICATIONS TO STUDENTS
CENTERVILLE COMMUNITY SCHOOL DISTRICT
ADMINISTRATION OF MEDICATIONS TO STUDENTS
Parental Authorization and Release Form
The undersigned are the parent(s), guardian(s), or person(s) in charge of:
_________________________________(student’s full name), a student in the _____ grade at the
_________________________________ building in the Centerville Community School District.
It is necessary that this student receive the following drug: ______________________________
In the following amount: __________________ (number of milligrams, teaspoons, cc’s, number of tablets) at the following time or times: ________________________,
beginning on _______(date) and continuing through _________ (date).
Special directives, signs to observe and side effects: _____________________________________________________________________________________________________________________________________________________________ _
Please be advised that we prefer to not give medication that is ordered once or twice daily unless it is specifically ordered by the health care provider to be given at a specific time which falls within the school day. Most medications can be given before or after school.
I hereby request the Centerville Community School District, or its authorized representative, administer the above-named drug to my child named above, in accordance with the prescribing physician’s instructions or the label instructions on a non-prescription medication, and agree to:
□ Submit this authorization to the building principal, school nurse, or authorized staff member.
□ Personally ensure that the drug is safely transported and received by the building office staff in the container in which it was dispensed by the prescribing physician or licensed pharmacist or the manufacturer’s container.
□ Personally ensure that the container in which the drug is dispensed is marked with the student’s name, drug name, dosage, dosage interval and time to be administered, and date after which no administration should be given.
□ Submit a REVISED STATEMENT signed by the physician prescribing the drug IF ANY OF THE PRESCRIBING INFORMATION PROVIDED BY THE PHYSICIAN CHANGES.
□ Give consent for school personnel to contact the prescribing physician, pharmacist, and parent or other emergency contacts to clarify prescribing information if needed, and to coordinate administration of medication.
□ Release the Board of Education of Centerville Community School District and their designated representative from any liability concerning the giving or non-giving of the drug to the student.
□ Authorize school personnel to dispose of any medication remaining at school after the last day of school for the student this academic year.
Today’s date_____________________
_______________________________ __________________________________________________
(name of student) (signature of parent or guardian)
____________________________ ______________________________ ______________________________
(daytime telephone number) (alternate telephone number) (contact telephone number)
____________________________ ______________________________
(name of prescriber) (telephone of prescriber)
Please call your building principal or the school nurse at 856-0806 or 856-0638 for assistance.
5/05;rev4/08; 01/09, 09/10, 6/11,3/17,8/2018,5/2020dg
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