Policy Title ADMINISTRTION OF MEDICATION TO STUDENTS

Medication Administration Authorization

To ensure compliance with the Board Policy for Medication Administration, the following MUST be completed:

- Parents have completed and signed the Medication Administration

Authorization form for all prescribed or over-the-counter medication.

- The medication is in the original, labeled container as dispensed by the

pharmacy or as bought in the manufacturer's labeled container.

- The medication label contains the student's name, name of medication,

dosage, directions for use, and date.

- Authorization is renewed annually and immediately when the parent

notifies the school that changes are necessary.

Student name____________________________ Birth date___________________

School ____________________________ Teacher/Grade____________________

Name of Medication_______________________ Dosage_____________________

Route (by mouth, etc.)_____________________ Time to be given_____________

Reason for Medication__________________________________________________

Possible Side effects/special instructions____________________________________

Physician Name________________________ Physician Phone______________

Start Date____________________ Stop/reevaluate Date________________

I request the above student receive the above medication at school and at school activities, according to the prescription and instructions. I understand the school will keep a written record. This information is confidential except as stated in the Family Education Rights and Privacy Act (FERPA). I agree to coordinate and work with the school personnel and the physician when questions arise. I agree to provide safe delivery of the medication and the equipment to and from school and to pick up the remaining medication/equipment.

Parent Signature______________________________ Date__________________

Parent's address______________________________ Phone_________________

Policy Title ADMINISTRTION OF MEDICATION TO STUDENTS

Additional Authorization for medication prescribed for ADD/ADHD:

Student name__________________________ Grade_________

Birthdate __________________________

I give permission to the Marion Independent School District to complete Behavior Checklists to help monitor medication administered to the above named student. I understand the checklists will be completed at least twice a year and two weeks after any dosage changes. I request the checklists be sent to the following physician and me.

Physician___________________________________

Address ___________________________________

___________________________________

Phone ___________________________________

This permission is good for one year from the date signed below. I may cancel permission by giving written notice to the Marion Independent School District and the physician listed above.

Parent Signature________________________________ Date___________________

Medication/Dosage to be monitored_________________________________________

Policy Title ADMINISTRTION OF MEDICATION TO STUDENTS Code No. 504-1-E2

Marion Independent School District

Authorization for Student's to Self Administer

Asthma Medication

Student_______________________ Birthdate____________

School________________________ Start Date___________

· I request the above student possess and self-administer Asthma medication at school and during school activities according to the authorizations and instructions.

· I understand the school district and its employees acting reasonably and in good faith shall incur no liability for any improper use of this medication or for supervising, monitoring, or interfering with a student's

self-administration of this medication.

· I agree to coordinate and work with school personnel and notify them when questions arise or relevant conditions change.

· I agree that I/my child will assume full responsibility for safe delivery/use/monitoring of this medication.

· I agree this information will be shared with school personnel in accordance with the Family Education Rights and Privacy Act (FERPA).

· If needed, I agree to provide the school with back-up medication approved in this form.

Parent Signature_________________________________ Date____________________

Parent Daytime Phone____________________________

I request that the above named student be allowed to carry and self-administer his/her Asthma medication.

Physician Signature______________________________ Date ___________________