CARY ACADEMY

MEDICATION ADMINISTRATION FORM

TO BE COMPLETED AND SIGNED EACH YEAR BY PHYSICIAN/DESIGNEE AND PARENT

NON-PRESCRIPTION MEDICATIONS

Absolutely no medications (non-prescription (over the counter) or prescription) will be administered by either school personnel or self( student) without the written authorization of a physician/designee and parent. Dosages for all medications will be administered according to manufacturer’s recommendations on the label unless otherwise indicated by physician. *** Generic Substitutions may be used for non-prescription medications listed. Please submit a new form during the school year if there are changes or additions. This form will also be the authorized form used for off campus activities, including overnight trips.

**TO BE COMPLETED AND SIGNED BY PHYSICIAN/DESIGNEE AND PARENT/GUARDIAN:

Child's name______Grade 2008-2009______

Drug Allergies (if none, state none)______

Non-Prescription Medications in Clinic:

Tylenol Tylenol liquid Tylenol Jr. Meltaways Tylenol Cold & Sinus Tylenol Children’s Cold Liquid Tylenol Sinus tablets Cough Drops Ibuprofen Ibuprofen Liquid Ibuprofen Children’s Cold Aleve

Excedrin Migraine Sudafed Sudafed PE Sinus Claritin 10 mg Zyrtec 10 mg Benadryl 25 mg

Benadryl Liquid 12.5 mg/5 ml Chloraseptic Throat Spray Pepto Bismol tablets or liquid Tums Mylanta Imodium Nausene Oragel/Orastat gel

Neosporin Ointment/Hydrocortisone Ointment/Benadryl Lotion Silvadene/Burn Cream or Gel

Insect Repellent Sunscreen All of the Medications Above None of the Above

Reason(s)______

Physician/Nurse Practitioner/Physician Asst.Signature: ______Date: ______

Parent/Guardian Signature: ______Date:______

PRESCRIPTION MEDICATIONS

**I request that my child be administered the prescription medication(per school personnel or self) as indicated in the physician's order below.

Parent/Guardian Signature: ______Date: ______

TO BE COMPLETED BY PHYSICIAN/NURSE PRACTITIONER/PHYSICIAN ASSISTANT:

Please list any prescription medication which would need administering during school or school related activities (whether administered by School Personnel or Self (Student).

______

Name and form of medication Dosage

______

Route Hours to be given

Possible side effects: ______

Order in effect until (date):______

______

Physician/Nurse Practitioner/Physician Assistant Signature Date

Physician Address/Phone Number: ______

Student may self administer medications listed above: Yes: ______No: ______

TO BE COMPLETED BY THE SCHOOL

Date Received______School Nurse ______