JLCD-E:  Medication Administration Consent Form

To be filled out by the parent/guardian prior to medication administration.

SCHOOL:

DATE:

1.   Medication must be brought to the school by the an adult and preferably the parent/guardian. The medication must be in a properly labelled and unaltered pharmacy container. Only under extenuating circumstances, agreed upon by the nurse, parent/guardian, and stated and signed below, may the student carry his/her own medication. This privilege of self-carrying medication can be revoked at any time by the building administrator and/or school nurse.

2.   Please fill out the following information:

STUDENT’S NAME:

DATE OF BIRTH:

MEDICATION:

DOSE TO BE GIVEN:

TIME TO BE GIVING:

PRESCRIBED BY:

REASON FOR IT TO BE GIVEN IN SCHOOL:

In the event the school nurse is called away, during field trips, or is unable to administer the above medication I give my permission for trained unlicensed staff to administer the medication listed above to my child.

PARENT/GUARDIAN SIGNATURE & DATE:

REVISED:  March 5, 2019