Medication Administration Form

Student's Name:*

First Last

Date of Birth:*

Grade:*

Daily Medication

Medication:

Dosage:

How it is to be given:

Time to administer:

Duration (all school year or specify):

Reason for Medication:

Does your child have another daily medication?

Yes

Medication:

Dosage:

How it is to be given:

Time to administer:

Duration (all school year or specify):

Reason for Medication:

Does your child have a another daily medication?

Yes

Medication:

Dosage:

How it is to be given:

Time to administer:

Duration (all school year or specify):

Reason for Medication:

As Needed Medication

Medication:

Dosage:

How it is to be given:

Time to administer:

Duration (all school year or specify):

Reason for Medication:

The above medication(s) are to be administered during the school day in accordance with above instructions. I agree to accept communication about the student and/or medication and understand that non-medical, trained school personnel may administer the medication(s).

Does your child have a another as needed medication?

Yes

Medication:

Dosage:

How it is to be given:

Time to administer:

Duration (all school year or specify):

Reason for Medication:

The above medication(s) are to be administered during the school day in accordance with above instructions. I agree to accept communication about the student and/or medication and understand that non-medical, trained school personnel may administer the medication(s).

Does your child have a another as needed medication?

Yes

Medication:

Dosage:

How it is to be given:

Time to administer:

Duration (all school year or specify):

Reason for Medication:

The above medication(s) are to be administered during the school day in accordance with above instructions. I agree to accept communication about the student and/or medication and understand that non-medical, trained school personnel may administer the medication(s).

Asthma Inhalers and EpiPens only:

It is my professional opinion that the student named above:

MAY carry and self-administer the above prescribed.
MAY NOT carry and self-administer the above prescribed.

He/she has been instructed in and understands the purpose and appropriate use of the medication.

The above prescribed is:

INHALER and/or
EpiPEN

FOR COMPLETION BY PARENT/GUARDIAN

Phone:*

Email*

We will send you a copy of this form entry for your records.

Date:*

As the parent/guardian of the above-named student, I have read and understand the school‘s medication policy and give the Raymond School District permission to administer the medication authorized by my physician. I will notify the school district immediately of any changes in medication profile or health concerns of my child. I authorize the District Nurse to contact the medical provider for clarification of this medical order or to report any adverse reactions or side effects.

Asthma Inhalers and EpiPens only:

I herby request that my child carry and self-administer the above inhaler/EpiPen. I have discussed this with my child and deem this responsibility appropriate for him/her.

Parent/Guardian Signature:*

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