"Permission Form for Dispensing of Medications in School - Main Street School"

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MAIN STREET SCHOOL
40 Main Street
Steve Adler, Principal
Denise Raisanen, R.N.
Exeter, N. H. 03833
603-775-8900
Permission form for the dispensing of medications in school
My child, _____________________________ is required by Doctor ___________________________,
the prescribing physician, to take the following medication during school time:
Name of medication: _________________________
Dosage: ______________
Time schedule to be observed:___________________
Method of taking medication: ______________________
Reason for taking medication: ____________________________
Possible adverse reactions:________________________________________________________
Other medication(s) student is taking at this time:_____________________________________
In the event of a medication emergency, please list persons to be notified other than parents and
physician: __________________________________________________________________________
Doctor’s phone #____________________ Parents’ #s __________________________________
Other Emergency Numbers
_____________________________________________________
Prescription medications must be accompanied by a written order from the
prescribing doctor and in a medicine bottle with the prescription label. The medicine
will be delivered, by the parent or guardian, to the school nurse in a pharmacy labeled container
listing the student’s name, the physician’s name, the medicine, and the instructions for this
medication.
Over the counter medication may be given, if needed, with the written request of the
parent/guardian. The medication must be supplied in its original container.
We, the parents, authorize the school nurse or any other member of the staff so designated by
the building principal to assist* our child in taking the above medication. Any pupil in grades
Kindergarten through the twelfth grade must be assisted by such persons, and the medication,
therefore, shall be in the custody of such persons. If the medication is an emergency
medication that must be carried by the student, a written permission form must be in the
nurse’s office. The nurse and the school principal must give sanction for this medication to be
carried by the student.
I, the parent or guardian, agree by signing this request form to the “HOLD HARMLESS”
Statement that follows: I agree that I will not hold liable any member of the school staff who is
directed by me to assist my child in taking the above stated medication.
*
Assist means having the required medication available to the child as needed and observing the student
as he/she takes or does not take his/her medication.
Parent’s/Guardian Printed Name
___________________________________________
Parent’s/Guardian Signature
_________________________________________
Date____________
MAIN STREET SCHOOL
40 Main Street
Steve Adler, Principal
Denise Raisanen, R.N.
Exeter, N. H. 03833
603-775-8900
Permission form for the dispensing of medications in school
My child, _____________________________ is required by Doctor ___________________________,
the prescribing physician, to take the following medication during school time:
Name of medication: _________________________
Dosage: ______________
Time schedule to be observed:___________________
Method of taking medication: ______________________
Reason for taking medication: ____________________________
Possible adverse reactions:________________________________________________________
Other medication(s) student is taking at this time:_____________________________________
In the event of a medication emergency, please list persons to be notified other than parents and
physician: __________________________________________________________________________
Doctor’s phone #____________________ Parents’ #s __________________________________
Other Emergency Numbers
_____________________________________________________
Prescription medications must be accompanied by a written order from the
prescribing doctor and in a medicine bottle with the prescription label. The medicine
will be delivered, by the parent or guardian, to the school nurse in a pharmacy labeled container
listing the student’s name, the physician’s name, the medicine, and the instructions for this
medication.
Over the counter medication may be given, if needed, with the written request of the
parent/guardian. The medication must be supplied in its original container.
We, the parents, authorize the school nurse or any other member of the staff so designated by
the building principal to assist* our child in taking the above medication. Any pupil in grades
Kindergarten through the twelfth grade must be assisted by such persons, and the medication,
therefore, shall be in the custody of such persons. If the medication is an emergency
medication that must be carried by the student, a written permission form must be in the
nurse’s office. The nurse and the school principal must give sanction for this medication to be
carried by the student.
I, the parent or guardian, agree by signing this request form to the “HOLD HARMLESS”
Statement that follows: I agree that I will not hold liable any member of the school staff who is
directed by me to assist my child in taking the above stated medication.
*
Assist means having the required medication available to the child as needed and observing the student
as he/she takes or does not take his/her medication.
Parent’s/Guardian Printed Name
___________________________________________
Parent’s/Guardian Signature
_________________________________________
Date____________