Student Name *. The student must be capable of self-administration and responsible behavior. closest regional office​. It does not indicate allow permission for the student to carry and use the medication independently. I request that the school nurse, or designated staff member, administer the medication(s) described below as directed by the above licensed health professional. Review Date. • Prescribed medications must be brought to schoolby an adult in a container labeled by the pharmacy or doctor with explicit directions. I give permission to the school nurse to administer medication to the above named child in accordance with the physician’s instructions, and communicate with the above named physician in regard to this medication/treatment. Over the counter medication must be labeled with child’s name. Online Resources. Some schools have given a “medication pass” to students, verifying school permission for the student to carry and take medication. All state schools Purpose. About our school; Supporting our students; Learning at our school; Gallery; Events; News; newsletter; Contact us; Parent Portal; Permission to Administer Medication; Canteen List; Search >Enter your search. J�"ì�2RI��5��$�+YZa�~\��ӅO�����+�A��g���+2��UnH��J��/ŋ �����u��`}���)�+������L�-���� :6f��ɯ�����vSa)LG�CA��mB Y�� J�o ^D%B@�{��J����Mn�`/��M#����I{}��W}��:ӥ���+N���T-:��}up��u�'�5���~���(��@+� All prescriptionmedication dispensed at school, including students who carry and self-administer Inhalers / Epi-Pens. 5.2 Implementation Date. The medication must be delivered in the original labeled container to the health office by … Refer to the Department of Education Policy and Procedure Register to ensure you have the most current version of this document. 4 0 obj _____ _____ Print Name of Physician/Licensed Prescriber Signature of Physician/Licensed Prescriber _____ _____ _____ Physician Clinic Address Phone Date 1. Please enable scripts and reload this page. 3. Box 800 • DeWitt, MI 48820 • 668-3000 Revised March 2003 5330.1 PERMISSION TO ADMINISTER MEDICATION All prescription and non-prescription drugs to be administered or kept at school for longer than 10 consecutive days must be accompanied by a written request signed and dated by the prescribing physician and the parent or guardian requesting this service. ާB�Zc�������~M1��r}�!���9���u6e�)��r��b��v���f�Xf�!c+{.���?/�A�-6�ԥ`9c���٩��>;Sմ����0X8�t����e�C s1 :2�C��A�T&�t����gy�º�1Ɋ�`9�����6ޡ\�`!�M�1{�R��g*��mTv��q��/|Z��#|y���b��[ڑ��k��R���@�C�-G7�U��֡�껳���Y���y��l�2B0�?K�G��=�8! (Child’s name) is/is not able to administer this medication independently and therefore will/will not require assistance from a trained member of staff. 3 0 obj However, the department must take reasonable steps to ensure that the self administration is carried out safely. Self-Administer/Self Carry Parent permission and provider consent is required for students to self-administer and self-carry medication. I agree to take responsibility for the delivery of the medication to the school and ensuring that all medication is with I give my permission for the school staff to contact the prescribing physician regarding this medication. Nurse (765) 269-4105 … Self-Administration Permission: NO YES, I request the above-named student be allowed to have personal possession of or access to the medication which I have prescribed and be permitted to self-administer this medication in accordance with the prescription and instructions provided. I also authorize, as needed, the sharing of information related to my child’s health on matters related to this medication, between the school nurse (or designee) and the health care provider listed below. to administer the following listed medication(s) to my child as prescribed on this authorization and in accordance with California law as referenced below. PERMISSION TO ADMINISTER MEDICATION AT SCHOOL District Selah School Fax 509-698-8185 Phone Student: _____ Birthdate: _____ Grade: _____ PARENT/GUARDIAN SECTION * SECCION DE PADRE/GUARDIAN I request that the school nurse, or designated staff member, administer the medication prescribed below, in accordance with the healthcare provider instructions and give permission for the medication … Process. ����n��Rg��wԏk��C�q�������Hzg�Â� -L���w�x2Λ���ԵN��� ����`���BR��d�[�/�j[7CbH��c�Y7 �Zc�H�_�F´�;�>���Ͱjgԟh���\���"M��|4������u;J���Ւ��.�H(I7k��������u������H; �!��u�g��wfih�V�n&��!��V�G��]Fb�g���*����nN̍@m�ѐz�Ql�A?�J�j`��f��܌f�����UE����uO�P/�8��\^�� �3\�\V��(Xs����3%��wX;-�h3�/���Kr�;�u���R�gf�$xrHs���i �ܦs��SY�V^�k,�ٱ�[F������� T2��S���-:O�xT/�R�X��U��!��YJA��Ⱦ�%o��*����M+�6 %PDF-1.5 PERMISSION TO ADMINISTER MEDICATION AT SCHOOL Easton School District Fax 509-656-2585 Phone 509-656-2317 Student: _____ Birthdate: _____ Grade: _____ PARENT/GUARDIAN SECTION * SECCION DE PADRE/GUARDIAN I request that the school nurse, or designated staff member, administer the medication prescribed below, in accordance with the healthcare provider instructions and give permission … revised: 11 -13 -2013 permission to administer medication during school hours to be completed by health care provider (for prescription or over -the -counter medication ) A new Parental Permission to Administer Medication form must be completed for each school year and any time there is a change in a student’s prescription medication or a change in the approved OTC medications for a student. , desks, or on them personally in your absence in original container school supervision your absence and... 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