Our District: Medical forms

PARENTAL REQUEST AND AUTHORIZATION

February 26, 2006

Code 504.4

Exhibit A

FOR THE ADMINISTRATION OF MEDICATION

I am the parent/guardian/custodian of_______________________________________

(student's full legal name), date of birth _____________________________in the

__________________Building in the Ogden Community School District.

My student's physician is__________, Telephone __________________

Address: _______________________________________________________________________ I request and authorize school personnel to administer the following medication to my child:

Name of Medication: _____________________________________

Date Prescribed:_________________________________________

Commence Administration on________________________________

Last Day for Administration_________________________________

Dosage, Time, and Method for Administration____________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Special Directions and Signs or Side Effects to Observe__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Do you want routine prescription medication that is usually given at 11:30 - 12:00 given on a day we have an 11:45 dismissal? _____Yes _____ No. [Please Note: In the event of early dismissals before 11:30 for any reason, medications will not be administered even if lunch is served. The nurse will not call to remind you. Please contact Tammy Wirtz, District Nurse, if you have a concern.]

I understand that the medication must be delivered to the school office in its original container.

I understand that if the medication is a nonprescription medication, there must be a physician's authorization giving the student's name, the name of the medication, the dates, times, and method of administration, and the dosage.

I understand that if the medication is a prescription medication, the pharmacy label must show the student's name, the date prescribed, the name of the medication, directions for use, the expiration date, the prescribing physician, the name and address of the pharmacy, any special storage or administration procedures, and a description of any anticipated reactions.

I understand I must submit a revised statement signed by the physician if any of the information changes.

I understand this request and authorization must be renewed each school year.

I agree to cooperate with school personnel and the prescriber of the medications if questions arise.

I agree to timely provide safe delivery of medication to and from school and to timely pickup remaining medications.

Dated this_______day of ______________ , ____________.

______________________ _____________________

Parent/Guardian/Custodian Home Telephone Number

______________________________

Business Telephone Number

_______________________________________________

Address

_____________________________________________

email address

Form Revised: March 21, 2005

Code 504.4

Exhibit B

PHYSICIAN'S REQUEST FOR THe

ADMINISTRATION OF MEDICATION

I am the physician of __________________________________ (student's full legal name), ___________________ (date of birth), a student in the Ogden Community School District. The student is under my care and must take medication which I have prescribed to be taken during the school day.

Name of medication (as it appears on the container in which the medication is stored):

This is a ________prescription ___________nonprescription medication.

Date administration is to begin: ____________________

Last date administration is to take place: ________________

Dosage, time and method of administration: ___________________________________________

Possible adverse reactions to be reported to parent or physician:

Other instructions:

_____________________________________

Signature of Physician

______________________________________ ____________________________

Printed Name of Physician Telephone Number

_______________________________