North Franklin School District 1100 W. Clark St/PO Box 829 Connell, WA 99326
509.234.2021 Fax 509.234.9200 nfsd.org
AUTHORIZATION FOR ADMINISTRATION OF MEDICATION AT SCHOOL Student:
Birthdate:
School:
Grade: THIS PORTION TO BE COMPLETED BY PHYSICIAN (one medication per form, please)
NAME OF MEDICATION
METHOD OF ADMINISTRATION
DOSAGE
TIME OF DAY TO BE TAKEN _
Reason for medication to be given during school hours:
Anticipated action 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 medication in accordance with the instructions indicated above for the period commencing with the _ day of , 20_ _, through the day of , 20_ , (not to exceed one school year) as there exists a valid health reason which makes administration of the medication advisable during school hours or during such time that the student is under the supervision of school officials. Such medication may be administered by medically untrained school personnel.
At the physician’s request, the student may carry the above listed medication on his/her person. For emergency situations, the student has been trained and is capable of self-administration.
Date of Signature
Licensed Health Professional’s Signature _
LHP’s Name (Print or Type)
Phone Number
Fax Number
THIS PORTION TO BE COMPLETED BY PARENT/GUARDIAN I certify that I am the parent, legal guardian, or other person in legal control of the above identified student and request and authorize the school to administer the above identified medication to the above identified student in accordance with the prescription or doctor’s instructions for the period commencing with the day of , 20_ , through the day of , 20_ , (not to exceed one school year) I understand this medical information may be shared with staff working for College Place School District. Medication will be supplied to school in the original Rx container. My child will carry an inhaler or Epi-pen on his/her person, and is trained and capable to self-administer. (I understand the prescribing LHP must approve this, before my child will be allowed to carry medication at school.)
Yes
No
N/A
If so, I will provide a second “back up” inhaler/Epi-pen for school. Yes The district shall incur no liability as a result of any injury arising from the self-administration of medication.
No
N/A
Date of Signature
Parent/Guardian Signature:_ Telephone (home):_
(cell):_
nfsd.org North Franklin School District is an equal opportunity employer and complies with all requirements of the ADA.
(work):_
Updated: 1/11/18
North Franklin School District 1100 W. Clark St/PO Box 829 Connell, WA 99326
509.234.2021 Fax 509.234.9200 nfsd.org
AUTORIZACION PARA LA ADMINISTRACION DE MEDICAMENTOS EN LA ESCUELA Estudiante:
Fecha de Nacimiento:
Escuela:
Grado: THIS PORTION TO BE COMPLETED BY PHYSICIAN (one medication per form, please)
NAME OF MEDICATION
DOSAGE
METHOD OF ADMINISTRATION
TIME OF DAY TO BE TAKEN
Reason for medication to be given during school hours:
Anticipated action 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 medication in accordance with the instructions indicated above for the period commencing with the day of , 20_ , through the day of , 20_ , (not to exceed one school year) as there exists a valid health reason which makes administration of the medication advisable during school hours or during such time that the student is under the supervision of school officials. Such medication may be administered by medically untrained school personnel. At the physician’s request, the student may carry the above listed medication on his/her person. For emergency situations, the student has been trained and is capable of self-administration. Date of Signature
Physician’s/Dentist’s Signature
Name (Print or Type)
Address
Phone Number
ESTA PORCION ES LLENADA POR EL PADRE O TUTOR Certifico que soy padre o tutor legal, u otra persona en control legal del mencionado estudiante, por lo que solicito y autorizo a la escuela le administre el medicamento indicado en ésta, de acuerdo con la receta o las instrucciones del médico, por el período que se inicia el de del 20_ , y termina el de del 20 (no exceda un año escolar). Entiendo que esta información médica puede ser compartida con el personal del distrito escolar de College Place. El medicamento será dado a la escuela en el envase original de la farmacia. Mi hijo/a llevará un inhalador o Epi-pen en su persona y es entrenado y capaz de autoadministrarse. (Entiendo que la prescripción LHP debe ser aprobada, antes de que mi hijo/a pueda llevar medicación a la escuela). Si No N/A Si es así, ofrezco una segunda "copia de seguridad" inhalador/Epi-pen para la escuela. Si No N/A l distrito no incurrirá ninguna responsabilidad como resultado de cualquier lesión que surja de la autoadministración de la medicación. Fecha de Firma
Firma del Padre o Tutor: Teléfono: (casa):_
(celular):_
nfsd.org North Franklin School District is an equal opportunity employer and complies with all requirements of the ADA.
(trabajo):_
Updated: 1/11/18
