Medication

EASTON-REDDING REGION 9 PUBLIC SCHOOLS

AUTHORIZATION FOR THE ADMINISTRATION OF MEDICATIONS BY SCHOOL PERSONNEL DURING THE NATURE'S CLASSROOM TRIP

ALL MEDICATIONS (NON-PRESCRIPTION AND PRESCRIBED) require a physician’s or dentist’s written order and parent/guardian’s authorization in order to be administered.

All non-prescription medications must be in their original containers and clearly labeled with the child’s name.

All prescribed medications must be in a pharmacy prepared container and labeled with the name of the child, name of the drug, strength, dosage, frequency, physician/dentist’s name and the date of the original prescription.

Child’s Name_____________________________ Address_____________________________________

Date of Birth______________________________ Allergies____________________________________

1)_________________________ _________________________ ____________________________

(medication) (dosage) (frequency)

___________________________ ________________________________________________________

(method of administration) (diagnosis/symptoms for which drug is to be administered)

2)_________________________ _________________________ ____________________________

(medication) (dosage) (frequency)

___________________________ ________________________________________________________

(method of administration) (diagnosis/symptoms for which drug is to be administered)

3)_________________________ _________________________ ____________________________

(medication) (dosage) (frequency)

___________________________ ________________________________________________________

(method of administration) (diagnosis/symptoms for which drug is to be administered)

Physician’s name______________________________ Address_________________________________

(type or print)

Physician’s signature___________________________ Telephone(_____)_________________________

Dentist’s name________________________________ Address_________________________________

(type or print)

Dentist’s signature_____________________________ Telephone(_____)________________________

I hereby request that the medication ordered by the physician/dentist for my child____________________________________________ be administered by school personnel.

Parent/Guardian_____________________________________ Date________________________

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