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

LHP’s Name (Print or Type)

___________________________________________________ Licensed Health Professional’s Signature ____________________________ ____________________________ 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.)

 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. Yes

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.

No

N/A

No

N/A



Updated: 5.22.2017

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). 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 El 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):_______________(trabajo):___________

CPPS.ORG College Place Public School District is an equal opportunity employer and complies with all requirements of the ADA.

Updated: 5.22.17