Guidelines for Policy 311.03

PHYSICIAN'S REQUEST FOR THE ADMINISTRATION OF MEDICATION

BY SCHOOL PERSONNEL

________________________ is under my care and should receive

Name of Student

__________________________ at the following times  _______________________     Name of Drug, Dosage, Route

Specific instructions for administration ________________________________________

Possible side effects to watch for ____________________________________________

Expiration date of this request ______________________________________________

Date ______________________           _______________________________________

                                                                            Physician’s Signature

                                                                _______________________________

                                                                            Physician’s Phone Number

PARENT'S REQUEST FOR THE ADMINISTRATION OF MEDICATION

BY SCHOOL PERSONNEL

I hereby request and give my permission to the principal or his/her delegate (school nurse or other responsible person) to administer the following medication to my child.