JLCD-R Authorization to Administer Medication in School

South Portland School Department Health Services
Which Must be Taken During School Hours

**All medication(s) must be in a clearly labeled container with student’s name, prescribed dosage and name of medication. Prescription medication must be in original prescription container. Your pharmacist can provide an additional labeled container for use at school.

Parental requests must be accompanied by a written order from the student’s physician/medical practitioner or dentist, substantiating the fact that the administration of a particular medication during the school day is necessary for the pupil’s health and attendance in school. Such order shall state any unique administration procedure, if appropriate.

**Parent/guardian must personally provide school with up to one week’s dosage unless other arrangements have been made with the school nurse.

Student’s Name: School: Grade:

Name of Medication:

Medication Description: Circle one (capsule, tablet, gel cap, liquid, drops, inhalants)

If Tablet: Shape: Markings (letter/#s): Color:

Dosage: Time to be given:

Doctor’s Name: Doctor’s Phone #:

Reason for Medication:

Are there any side effects that school staff should be aware of?

Termination date (not beyond the current school year):

Medication Removal
Only a limited, necessary supply of medication(s) can be kept in the school. Medication(s) no longer required must be removed by the parent/legal guardian. Furthermore, it shall be the parent’s responsibility to notify the school of any changes in or the discontinuation of a prescribed medication that is being administered to the child in school.
Informed Consent of Parent/Legal Guardian
*I hereby request that school department personnel administer the above medication to my child. I am aware that this medication may be administered by medical or non-medical school personnel.
*I give my permission for the school nurse to contact the above named prescribing physician to obtain information about the medication and the administration schedule. I give permission for the school nurse to share information with the doctor about the effects of the medication on my child’s learning.
I understand that information regarding the student’s medication may be shared with appropriate school personnel.

Parent/Legal Guardian Signature Home Phone Number

Date Work Phone Number

Revised: November 19, 2002
Adopted: December 9, 2002

If you need assistance with translation of this document, please contact Instructional Support at 871-0555.

Si desea que esta traducida, por favor comuníquese con la oficina de Apoyo Educativo en el 871-0555.

Nếu bạn muốn có này dịch, xin vui lòng liên hệ với văn phòng hỗ trợ giảng dạy tại 871-0555.

Hadii aad dooneysid in laguu tarjumo fadlan la soo xiriir Xafiiska caawinta wax barasho ee telefoonkeedu yahay 871-0555