Authorization for Administration of Oral Medication at School

LIBERTY SCHOOL DISTRICT, #362

S. 29818 North Pine Creek Road

Spangle, WA 99031

Kyle Rydell, Superintendent

Liberty Elementary/Junior High Liberty High School

Kyle Rydell, Principal Aaron Fletcher, Principal

Telephone: (509) 245-3211 Telephone: (509) 245-3229

Fax: (509) 245-3530 Fax: (509) 245-3205______

Authorization for Administration of Medication at School

Student Name: ______Birthdate:______

School: ______Teacher/Grade: ______

…………………………………………………………………………………………………………………..

THIS PORTION TO BE COMPLETED BY LICENSED HEALTH PROFESSIONAL WITH

PRESCRIPTIVE AUTHORITY

Name of Medication:______Strength:______Dosage: ______

Method of Administration: ______Time of Day to be given: ______

If to be given as needed (prn), specify minimum length of time between doses:______

Diagnosis: ______

Possible side effects of medication: ______

Emergency procedure in case of serious side effects: ______

I request and authorize that the above named student be administered the above identified oral medication in accordance with the instructions indicated above from ______to ______(not to exceed the current school year). There is a valid reason which makes the administration of this medication necessary during school hours.

Date of Signature:______Signature: ______

Telephone #: ______Fax #: ______Print Name: ______

…………………………………………………………………………………………………………………

THIS PORTION IS TO BE COMPLETED BY A PARENT/GUARDIAN

I request and authorize the Liberty School District to administer the above ordered medication for my student in accordance the directions given from ______to ______(not to exceed the current school year). Medication will be supplied to the school in the original container with the pharmacy label attached which includes the student’s name, medication, dosage and time to be given.

Date of Signature: ______Parent/Guardian Signature:______

Home Phone #: ______Work/Cell Phone#: ______

LIBERTY SCHOOL DISTRICT # 362

S. 29818 North Pine Creek Road

Spangle, WA 99031

(509) 624-4415

Parent Information on Medication at School

In accordance with Washington State law, administration of medication may be provided at school if all conditions are met. Medication is ordered to be given to a student at school only when necessary. Whenever possible, the parent and physician are urged to design a schedule for giving medications outside of school hours. If this is not possible, it is understood by the parent that the medication will be dispensed by the school nurse, the principal or his/her designee. Only medications with completed Medication Authorization forms will be dispensed. The principal will designate the person responsible for giving medications on an individual basis. The school accepts no responsibility for untoward medication reactions when the medication is dispensed in accordance with the physician’s directions. It is the parent’s responsibility to maintain the supply of medication. The medication authorization is valid only for the current school year and must be renewed annually. The parent also understands and agrees that it is possible, because of the school schedule and other responsibilities, a dose or dosages may be delayed or missed. In such instances, the parent will be notified before a delayed medication is given or if a medication dosage is missed.

All Medication

Must be brought to the school office by the parent and not the student.

Pills need to be broken or cut prior to being brought to school for half doses.

Medication will be counted by the school staff and parent, and the acceptance log signed by both for all medication brought to school.

Medication left at school will be destroyed on the last day of school, unless previously picked up or arranged between the parent and the school nurse.

Prescription Medication

An Authorization for Administration of Medication at School form must be completed and signed by the parent and a licensed health professional prescribing within the scope of his/her prescriptive authority.

All medication must be in the original prescription bottle and properly labeled with the student’s name, name of medication, exact dosage, name of prescribing licensed health professional, the date and time of day to be given.

The directions on the Authorization form must match the directions on the prescription label.

Sample medication must also be properly labeled and in the original container or package.

Non-Prescription Medication

(e.g. – cough drops, vitamins, aspirin, Tylenol or any other over-the-counter medication)

An Authorization for Administration of Medication at School form must be completed and signed by the parent and the licensed health professional prescribing within the scope of his/her prescriptive authority.

No medication shall be given without this Authorization form.

Non-prescription medication must be in its original package and must be labeled by the parent with the student’s name.