MEDICATIONS TO BE ADMINISTERED AT SCHOOL

BYRAM TOWNSHIP SCHOOLS

MEDICATION AUTHORIZATION FORM

DATE___________________ SCHOOL____________________

To be completed by PARENT/GUARDIAN:

I give permission for (name of student)_____________________Grade_____________

to receive medication at school according to standard school policy. I understand that

the medication must be delivered to the nurse in the original pharmacy container, with the

student’s name on it. I understand coaches and advisors cannot give medications. I will contact the nurse if there is a change in the medication or dosage.

_________________________ ________________________ _________________

Date Parent/Guardian Signature Home Phone

________________________________________________________________________

To be completed by PHYSICIAN:

1. Diagnosis for which medication is prescribed_________________________________

2. Name of medication_____________________________________________________

3. Dosage__________tablet/capsule_________liquid_________inhaler_____other_____

4. Time to be administered by school nurse____________________________________

5. Time and dosage when medication is given at home___________________________

6. Describe indication for “PRN” medication is to be given_______________________

7. How soon can the medication be repeated___________________________________

8. Restrictions and/or important side effects: NONE ANTICIPATED______YES_____

____________________________________________________________________

9. How long has the student been taking this medication__________________________

10. Other information/comments____________________________________________

________________________ _______________________

Physician’s Signature Date

________________________ _______________________

Physician’s Stamp Phone