PARENT REQUEST FOR ADMINISTRATION OF PRESCRIPTION MEDICATION

Name of Student:_______________________________________Birth date:______________________

School:_____________________________________Teacher/Section:___________________________

PENN MANOR SCHOOL DISTRICT

I request that medication be administered to my child,_____________________________, in accordance with our physician's written instructions. I understand that designated school personnel will administer medication under the supervision of a certified school nurse. I will notify the school immediately and submit a new form if there are changes in medication, dosage, time of administration, and/or the prescribing physician. I give permission to contact the physician when necessary.

Parent/Guardian Signature:_________________________________________Date:________________

Telephone: (work) ______________(home)_______________

Medication must be in the student's original, labeled pharmacy container. You may request two labeled containers from your pharmacist, one for school and one for home. If it is impossible for you to give the medication at home, this form must be completed by your physician.

PHYSICIAN REQUEST FOR ADMINISTRATION OF MEDICATION

Diagnosis/Reason for Medication:______________________________________________

1.Name of Medication ______________________Dosage_____________Time to Be Taken_________

2.Name of Medication ______________________Dosage_____________Time to Be Taken_________

3.Name of Medication ______________________Dosage_____________Time to Be Taken_________

4.Name of Medication ______________________Dosage_____________Time to Be Taken_________

Possible reactions:___________________________________________________________________

The above medication cannot be administered at school except during the regular school day. The medication may be administered by non-medical, school personnel under the supervision of a school nurse.

Physician's Signature:______________________________Telephone:____________

Date of request:___________________________________Date to Discontinue Medication:___________

This request is valid for a maximum of one school year. New forms must be submitted at the beginning of each school year or when there is a change in medication/s, doses, or physician.