Medication Request Form

Students Name__________________________________________ Grade____________

Parent’s Name____________________________________________________________

Parent’s Address__________________________________________________________  

Phone Numbers:   Home____________      Work____________        Cell______________

Doctor’s Name______________________   Phone Number________________________

I request that the School Nurse, or other delegated school personnel, administer the following medication to the above named student.
Name of medication(s)_____________________________________________________

Has your child received at least one dose of this medication?        Yes_____        No_____

Reason for medication(s)___________________________________________________

What time should medication be given at school?________________________________

How much medication should be given?_______________________________________

If appropriate, can this medication be repeated?     Yes______     No_______

          If yes, how soon?_________________

How long will the student be taking the medication?______________________________

Should short-term medication (cough medicine, antibiotics, inhalers, etc.) be sent home daily?    Yes______     No______

I have reviewed the U.S.D. #489 Medication Request Procedure and agree to the stipulations attached.   Please note that medical and health related information may be shared with appropriate school personnel.

 Signature of Parent or Guardian______________________________________________

Date______________________

Students requiring daily medications will be responsible for reporting to the Health Office at the specified time.             5-03