COLLEGE PLACE PUBLIC SCHOOLS
Health Services
1755 S. College Avenue College Place, WA 99324 509.525.4827 Fax 509.525.3741 Cpps.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 ________________ ____
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
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) Medication will be supplied to school in the original Rx container.
Date of Signature ________________ Parent/Guardian Signature:_________________________________________________ Telephone (home):_______________ (cell):_______________(work):_______________ CPPS.ORG College Place Public School District is an equal opportunity employer and complies with all requirements of the ADA.
Updated: 1.14.16
COLLEGE PLACE PUBLIC SCHOOLS 1755 S. College Avenue College Place, WA 99324
Health Services
509.525.4827 Fax 509.525.3741 Cpps.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). El medicamento será dado a la escuela en el envase original de la farmacia.
Fecha de Firma ________________
Firma del Padre o Tutor:_________________________________________________ Teléfono: (casa):______________ (celular):_______________(trabajo):___________
CPPS.ORG College Place Public School District is an equal opportunity employer and complies with all requirements of the ADA.
Updated: 1.14.16
