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Administration of Medication Form
2/13/2014

GREENVILLE AREA SCHOOL DISTRICT

9 DONATION ROAD

GREENVILLE, PA 16125

 

Dear Parent or Guardian:

 

The Greenville School District recognizes that parents have the primary responsibility for the health of their children. Although the district strongly recommends that medication be given at home, it realizes that the health of some children requires that they receive medication while in school. When medication absolutely must be given during school hours, certain procedures must be followed.

 

Instructions to the school nurse or school district designee for the administration of medication or treatment required during the school day.

 

 

SECTION I

 

NAME OF STUDENT _________________________________ HOME PHONE _____________

 

SCHOOL _______________________________ GRADE _________ TEACHER ____________

 

 

                                                                        SECTION II

 

To be completed by the parent for short-term prescription medication (antibiotics) or non-prescription medication.

 

NAME AND ADDRESS OF PHYSICIAN _________________________________________________________________________________

 

_________________________________________________________________________________

 

NAME AND TREATMENT/MEDICATION__________________________________________

 

DATE MEDICATION/TREATMENT TO BEGIN ____________ DATE CEASES__________

 

DOSAGE ____________________ EXACT TIME OR TIME RANGE ____________________

 

ALLERGIES _____________________ SPECIAL INSTRUCTIONS ______________________

 

________________________________________________________________________________

 

SECTION III

 

To be completed by a physician for long-term prescription medication or emergency medication (e.g. Ritalin, asthma or seizure –controlling meds.)

 

NAME OF MEDICATION OR NATURE OF TREATMENT ____________________________    

_________________________________________________________________________________

 

PURPOSE OF MEDICATION/TREATMENT ________________________________________                

___________________________________________________________________DATE________

 

MEDICATION/TREATMENT TO BEGIN ___________________________________________

DATE CEASES __________________

DOSAGE _______________________ EXACT TIME OR TIME RANGE __________________

SPECIAL INSTRUCTIONS________________________________________________________

_________________________________________________________________________________

 

POSSIBLE REACTIONS ­__________________________________________________________

_________________________________________________________________________________

 

KNOWN ALLERGIES ____________________________________________________________

_________________________________________________________________________________

 

PROCEDURE TO FOLLOW IF REACTION SHOULD OCCUR

_________________________________________________________________________________

 

PERSON TO CONTACT _______________________________ PHONE ___________________

 

DOES MEDICATION REQUIRE REFRIGERATION?   YES _______   NO _______

 

PLEASE RETURN THIS FORM WITH THE MEDICATION

 

_________________________________________________________________________________

Signature of Physician                                                                                                           Date

 

SECTION IV

 

I hereby authorize the medication/treatment listed above to be administered to my child or charge. Furthermore, I release the Greenville School District and its employees from liability claims which may be brought as a result of district employees carrying out their assigned duties in good faith.

 

_________________________________________________________________________________

Signature of Parent/Guardian                                                                                              Date