Henry County Public Schools

HENRY COUNTY PUBLIC SCHOOLS______School Year

AUTHORIZATION TO ADMINISTER MEDICATION

**A separate form must be completed for each medication**

**This form should not be used for chronic conditions with emergency meds (ie…epi pen, inhaler, insulin, and diastat). These conditions require a specific care plan**

**TO BE COMPLETED BY SCHOOL PERSONNEL**
School: ______Date form received: ______
I acknowledge receipt of this Authorization to Administer Medication form: ______

Student Name: ______Student age: ______Date of Birth: ______

Grade: ______Homeroom/Classroom: ______

List all known allergies: ______

Name & dose of medication: ______Reason for medication: ______
Form of medication/treatment: [ ] Tablet/capsule [ ] Liquid [ ] Inhaler [ ] Injection [ ] Nebulizer [ ] Other ______
Instructions (Schedule and dose to be given at school): ______
______
Start: [ ] Date form received [ ] Other, as specified: ______
Stop: [ ] End of school year [ ] Other date/duration: ______
[ ] For episodic/emergency events only
Restrictions and/or important side effects:[ ] No restrictions [ ] Yes (describe) ______
Special storage requirements: [ ] None [ ] Refrigerate [ ] Other ______
** Self-Administration for over-night and extended day field trips ONLY*
In some situations, students in Middle and High school ONLY may be authorized to self-administer their medication while on school-sponsored trips. A school employee will be responsible for keeping the medication in a safe and secure place while on a field trip until such time that the student requires the medication. At the appropriate time, the medication will be available to the student to self-administer in the presence of the school employee. School policy must be followed in all other aspects of the administration of this medication.
**TO BE COMPLETED BY PHYSICIAN OR AUTHORIZED PROVIDER** (Prescription medication only)
Your signature serves as the medical order for administration of this medication in the school setting.
For over-night and extended day field trips (Middle and High School students ONLY), you confirm that you have instructed the student on self administration of this medication and verify that this student is competent and capable to safely and effectively self administer this medication in the presence of a school official as outlined above: [ ] YES [ ] NO
Physician signature: ______Date: ______
MD name: ______Phone: ______Fax: ______
**TO BE COMPLETED BY PARENT/GUARDIAN**(Prescription and Over the Counter medication)
“I have read and understand Henry County Public School’s Medication Administration policy and agree to abide by said policy regarding the administration of medication to my child while at school or school functions. I expressly waive any liability on behalf of Henry County Public Schools and school personnel as a result of the administration of the above medication.”
In addition, if your middle or high school student will be involved in a school field trip, you verify that he/she is competent and capable to safely administer this medication in the presence of a school employee if neededas outlined above: [ ] YES [ ] NO
Parent Signature: ______Relationship to child: ______
Date: ______Home phone: ______Work phone: ______Cell phone: ______

Procedure 09.2241 AP .21