JLCD-E Medication Administration on School Field Trips
EPN/NSBA Code: JLCD-E 

SAD#4 MEDICATION PERMISSION FORM
NURSE: Wendy J Viera, RN                  PHONE: 876-4633                    FAX: 876-4291

 

SAD#4 shall dispense medication in the school only when the student’s health requires that the medication must be given during the school hours.
Medication must be in the original container. Written authorization from the student’s parent/guardian is required. All medication will be
appropriately maintained and secured by the school and will be administered under the supervision of the school nurse. By policy, some trained
Unlicensed Personnel may administer medications.

Prescription Medicines need signed consent of the parent/guardian AND the health care provider if it is on-going for more than 15 days.

Non-prescription Medicine need signed consent from the parent/guardian.

Student Name: ________________________________________________DOB:_________________________

Teacher: _____________________________________________________Grade:________________________

To be completed by health care provider for prescription medicine:

Medication: ___________________________________________________Time:_________________________

Dosage: ______________________________________________________Route:_________________________

Adverse Reactions____________________________________________________________________________

Diagnosis (optinal):___________________________________________________________________________

Administration of Medication: Check one only

(     )     Supervised: Medication is stored in Nurse’s office. Student presents him/herself to receive medication.

            (     )     Unsupervised: Student is allowed to carry his/her inhaler/Epi-pen/diabetic equipment and administer it without supervision.
    (Health care provider and school nurse must confirm that student possesses the knowledge and skills to safely possess and administer medication).

Health Care Provider’s signature: ______________________________________________________________

Printed Name: ________________________________________________ Date__________________________

Phone Number: _______________________________________ Fax: __________________________________

To be completed by Parent/Guardian: I give permission for my child to receive this medication at school according to SAD#4’s medication
a
dministration policy. I agree that I will supply the prescription medication in its original container, labeled with the student’s name. I give
permission for the school nurse to contact the health care provider about this medication if the need arises. I understand that non-medically
licensed school personnel may be dispensing/administering this medication.

If my child is authorized to self-administer his/her medications, I understand that the school cannot accurately monitor the frequency and
appropriateness of the use of these medications and will not be responsible for any injury arising from the student’s self-medication.

All medications must be delivered to the school by the parent/guardian except inhalers, Epi-pens, and diabetic supplies which may be carried
by the student after this medication form is completed.  It is the responsibility of the parent/guardian to notify the school of any changes in medication.


Parent/Guardian Signature: ____________________________________ Date:_____________________

Nurse Signature: ______________________________________________ Date:_____________________


Adopted:  December 13, 2016

M.S.A.D. #4