"Long Term Non-prescription Medication Request Form - Anchorage School District"

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L
T
N
-P
M
R
ONG
ERM
ON
RESCRIPTION
EDICATION
EQUEST
S
N
(P
): _____________________________ A
:______ G
: _______ S
I.D. # ________________
TUDENT
AME
RINTED
GE
RADE
CHOOL
Allergies (Medication): _________________________________________________________________________________
As parent/guardian of the above named student, I request the School District to give medicine for the following condition(s) (Check all that apply)
C
:
Headache
Cramps
Dental
Other: _______________________________________________
ONDITION
M
:
Acetaminophen
Ibuprofen
Naproxen
Midol/Premsyn/Pamprin
Other _____________________________
EDICINE
Dose: ___________________ Frequency: _____________________ Specify Time: _________________ or As Needed: ___________________
I understand that the school is not legally obligated to administer medication to my child. Therefore, I agree to defend and hold harmless, the school district and
its employees from any liability for the results of the medication or the manner in which it is administered, and to defend and indemnify the school district and
its employees for any liability arising out of these arrangements. Medication request must be deemed necessary to maintain or improve health and participation
in the school program. Each request will be assessed for the most appropriate intervention and will be given at the standard dosage recommended by
manufacturer. I will notify the nurse if I give this medication to my child before arrival at school while this request is in effect to prevent overmedicating. I agree
to supply medication for my student in its original packaging (small bottles only, please). I also affirm that my child has taken this medicine at least two times in
the past without any adverse side effects. I understand that the medicine will be destroyed unless picked up by the end of the last student school day of this
year. Medicines will not be kept by the school over the summer break per DEA regulations.
_________________
Parent/Legal Guardian Signature: __________________________ Printed Parent Name: _____________________ Date:
O
C
M
A
R
VER THE
OUNTER
EDICATION
DMINISTRATION
ECORD
D
~T
~I
D
~T
~I
D
~T
~I
D
~T
~I
D
~T
~I
D
~T
~I
ATE
IME
NITIALS
ATE
IME
NITIALS
ATE
IME
NITIALS
ATE
IME
NITIALS
ATE
IME
NITIALS
ATE
IME
NITIALS
Initials_______
Name ____________________________
Initials_______
Name ___________________________
Initials_______
Name ____________________________
Initials_______
Name ____________________________
Anchorage School District
Revised 6/2013
Nursing & Health Services, NUR # 0523
Page 1 of 1
Print Form
Reset Form
L
T
N
-P
M
R
ONG
ERM
ON
RESCRIPTION
EDICATION
EQUEST
S
N
(P
): _____________________________ A
:______ G
: _______ S
I.D. # ________________
TUDENT
AME
RINTED
GE
RADE
CHOOL
Allergies (Medication): _________________________________________________________________________________
As parent/guardian of the above named student, I request the School District to give medicine for the following condition(s) (Check all that apply)
C
:
Headache
Cramps
Dental
Other: _______________________________________________
ONDITION
M
:
Acetaminophen
Ibuprofen
Naproxen
Midol/Premsyn/Pamprin
Other _____________________________
EDICINE
Dose: ___________________ Frequency: _____________________ Specify Time: _________________ or As Needed: ___________________
I understand that the school is not legally obligated to administer medication to my child. Therefore, I agree to defend and hold harmless, the school district and
its employees from any liability for the results of the medication or the manner in which it is administered, and to defend and indemnify the school district and
its employees for any liability arising out of these arrangements. Medication request must be deemed necessary to maintain or improve health and participation
in the school program. Each request will be assessed for the most appropriate intervention and will be given at the standard dosage recommended by
manufacturer. I will notify the nurse if I give this medication to my child before arrival at school while this request is in effect to prevent overmedicating. I agree
to supply medication for my student in its original packaging (small bottles only, please). I also affirm that my child has taken this medicine at least two times in
the past without any adverse side effects. I understand that the medicine will be destroyed unless picked up by the end of the last student school day of this
year. Medicines will not be kept by the school over the summer break per DEA regulations.
_________________
Parent/Legal Guardian Signature: __________________________ Printed Parent Name: _____________________ Date:
O
C
M
A
R
VER THE
OUNTER
EDICATION
DMINISTRATION
ECORD
D
~T
~I
D
~T
~I
D
~T
~I
D
~T
~I
D
~T
~I
D
~T
~I
ATE
IME
NITIALS
ATE
IME
NITIALS
ATE
IME
NITIALS
ATE
IME
NITIALS
ATE
IME
NITIALS
ATE
IME
NITIALS
Initials_______
Name ____________________________
Initials_______
Name ___________________________
Initials_______
Name ____________________________
Initials_______
Name ____________________________
Anchorage School District
Revised 6/2013
Nursing & Health Services, NUR # 0523
Page 1 of 1