CONSENT FOR ADMINISTRATION OF MEDICATION AT SCHOOL by pengtt

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									                                                                                                                                                          Rev. 1/4/07 (TF)



                    CONSENT FOR ADMINISTRATION OF MEDICATION AT SCHOOL

NAME OF STUDENT________________________________________________ BIRTHDATE____________________________

NAME OF MEDICATION_____________________________________________Time to be given _________________________

REASON FOR MEDICATION____________________________ Dosage_______________ Length of treatment_______________

NAME OF PHYSICIAN (please print) _____________________________________ PHONE NUMBER_____________________

Please check and initial the appropriate box below:
My child is knowledgeable, capable, & responsible to transport his/her medicine to and from school.  YES-Parent/Guardian Initials________
My child is NOT knowledgeable, capable, & responsible to transport his/her medicine to and from school.  NO-Parent/Guardian Initials________

BY SIGNING, I AUTHORIZE DESIGNATED SCHOOL PERSONNEL TO GIVE THE ABOVE MEDICATION, AS WELL
AS RELEASE THE DISTRICT, THE BOARD AND SCHOOL EMPLOYEES FROM ANY LIABILITY RELATED TO AN
ALLERGIC/ADVERSE REACTION TO THIS DRUG. IF ELECTED, I ALSO EXCEPT RESPONSIBILITY FOR ANY
DAMAGE, INJURIES OR OTHER EVENTS THAT MAY RESULT FROM MY CHILD TRANSPORTING MEDICATION.

PARENT/GUARDIAN’S SIGNATURE______________________________DATE___________PHONE NUMBER_____________
Medication is recognized as prescription as well as nonprescription drugs and includes, but is not limited to: analgesics, antipyretics, antacids, antibiotics,
antihistamines, decongestants, and cough/cold preparations. The school district does not provide medication for students and only medications provided by and
requested by a parent/guardian will be administered. To comply with Texas State Law, as well as LISD policies, the following restrictions apply to the taking of
medication by students while in school:

                      1. Medication may be administered to students by a school employee assigned to the task by the building principal.

                      2. All medicine is to be brought to and kept in the school nurse’s office. Asthmatic or emergency medications that
                         needs to be kept on his/her person must have a doctor’s and parent/legal guardian’s written consent giving
                         the student permission to carry and self medicate.

                      3. Prescription and nonprescription medicine must in the original container. Prescription medicine must be in
                         the original container with the pharmacy label for that student. Pharmacy label date must be current.
                         No expired medications will be accepted.

                      4. If prescription or nonprescription medicine must be given during the school day, it must be accompanied by a note,
                         which includes time and dosage. The note must be signed by a parent or guardian giving authorized school personnel
                         directions for its administration. The medication must be age appropriate. Parent/Guardian consent for each medication
                         is valid for the length of the current school year, unless revoked or a change occurs.

                      5. Herbal substances or dietary supplements will only be given with a doctor’s and parent/legal guardian’s written consent,
                         and only if required by the Individualized Education Plan or Section 504 plan of a student with disabilities.

                      6. Medications that are prescribed to be given up to three times a day can be given at home. If there is a clear reason why
                         the school personnel should give the medicine, please have the prescribing physician write an order for the school. Information
                         may be faxed to the school. *Medications prescribed may be given as follows, at home, and can be given with milk and/or
                         bread/crackers if they are labeled to take with food:
                                 *Once a day medications should be given in the morning or at bedtime.
                                 *Twice a day medications should be given in the morning and at bedtime.
                                 *Three times a day medications should be given in the morning, right after school,
                                  and at bedtime
.
                      7. A physician’s written request is required on all medications that are to be administered for more than 10 consecutive days.

                      8. School personnel will not give any medicine, including Tylenol, unless it is provided by you, in the appropriate manner
                         as stated above.

                      9. The District, the Board, and its employees shall be immune from civil liability for damages or injuries resulting from the
                         transportation of medication by a student or the administration of medication to a student under the guidelines of this policy
                         except for acts constituting gross negligence.

Providing protection for students as well as our staff is of utmost importance as we endeavor to administer medication at school. Please feel free to call the nurse on
your students campus if you have any questions. Your cooperation is greatly appreciated.


_____________________________________                                                      _______________________________________
Principal                                                                                  School Nurse

								
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