H.S. 40-83, R4/99
CARROLLTON-FARMERS
BRANCH I.S.D.
Permission to Administer Medication
Parents: Complete this form and return
to the Clinic with the medication to be given.
I hereby request and grant permission to the Carrollton-Farmers Branch I.S.D. to administer medication to my child. If the school nurse deems it necessary, I also grant the nurse permission to notify my child’s teacher(s), either verbally or in writing, of this medication and of possible reactions that might occur. I further state that this medication cannot be scheduled for other than school hours. I understand that oral medication, inhalers, nebulizers and oxygen administration may be given by a medically untrained designate of the principal as per Texas Education Code, Section 22.052.
Student’s Name:
_____________________________________________ Grade: ____________
Condition for which medication
is to be given: ________________________________________
|
Name of Medication |
Dosage |
Time for Each Dosage (Non-prescription drugs cannot be given “as needed” except by
a doctors order) |
|
1. |
|
|
|
2. |
|
|
|
3. |
|
|
Special Instructions; if any
________________________________________________________
Date Requested: ______________________ Date of Termination: ________________________
_______________________________________________
___________________________
Telephone Number Parent’s Signature
_______________________________________________
Email Address
I wish my child’s medication to be sent on Field Trips. yes no
School has my permission to give the AM dose when it is not given at
home. yes no
I wish to be notified prior to giving the
missed dose. yes no
PLEASE NOTE THE FOLLOWING MEDICATION POLICIES
1.
All medication must be in its original container and be properly
labeled. The pharmacy label must state
the student’s name, medication, dosage, doctor’s name, and date prescription
was filled. The prescription is to be current within the last 12 calendar months. Non-prescription drugs should have the
student’s name affixed to the original bottle.
2.
After five (5) consecutive school days, students on non-prescription
drugs will be required to submit a physician’s authorization for continuance of
medication.
3.
Any unused medication left over two weeks after the last dosage will be
destroyed.
4.
Changes in prescription medications require either a new prescription labeled bottle
or written physician request for dosage change.
A new parental permission request is to accompany any change in
medication.
5.
It is requested that medication be brought to the clinic by the parent
and given to the school designated person.
No medication will be transported by any school transportation service
personnel.
6.
Vitamins, minerals, diet supplements, and special diets will not be
administered by school staff except from a physician’s written order.