 Madison Central School District 7303 Route 20 Madison, New York 13402 Phone: (315)893-1878 Fax (315)893-7111 AUTHORIZATION FOR ADMINISTRATION OF MEDICATION
A. To be completed by the Licensed Health Care Prescriber: I request that my patient, as listed below, receive the following medication: Name of Student: ________________________________ Date of Birth: __________________ Diagnosis: ___________________________________________________________________ Name of Medication: ___________________________________________________________ Prescribed dosage and route of administration: ________________________________________ Frequency and time to be taken during school hours: ___________________________________ Duration of treatment: _________________________________________________________ For PRN medications - list conditions under which medication should be administered: __________________________________________________________________________ Name of Licensed Prescriber & Title (please print): ___________________________________ Prescriber's signature: ______________________________ Date: ______________________ Issuing Physicians Office: __________________________ Phone: ______________________
B. To be completed by parent or guardian: I request that my child ___________________________________ grade _________________ receive the medication as prescribed above by a our licensed health care prescriber. The medication is to be furnished by me in the properly labeled original container from the pharmacy. I understand that the school nurse, or other designated person in the case of the absence of the school nurse, will administer the medication. I also hereby request that my child's teacher or other designated faculty member administer the medication on such school-sponsored activites such as field trips, athletic events, etc. during the ______________ school year. The above medication is to be administered during the current school year or ountil terminated by written notice.
Signature of Parent/Guardian: ____________________________________________________ Address: ____________________________________________________________________ Phone (home): ________________________ Phone (work): ___________________________ Date: _______________________________ |
|
|
|