HENRY-SENACHWINE

SCHOOL MEDICATION AUTHORIZATION FORM

 

To be completed by the child's parent(s) guardian(s) and kept in the school nurse's office or, in the absence of a school nurse, the Building Principal's office:

   

Student’s Name ___________________________________________  Birth Date _____________________

Address ________________________________________________________________________________   

Home Phone _________________________     Emergency Number _______________________________

School: Henry-Senachwine Grade School     Grade __________   Teacher __________________________   

Medication: _________________________________________ Dosage:____________________________

Frequency:__________________________________________________________
     
*TO BE COMPLETED BY THE STUDENT'S PHYSICIAN: (for prescription drugs only)

Physician's Printed Name: __________________________________________________________________

Office Address: ___________________________________________________________________________

Office Phone: _____________________________   Emergency Phone: ______________________________

Medication: _______________________________________________________________________________   

Dosage: ______________________________   Frequency: ________________________________________

Time medication is to be administered or under what circumstances: ________________________________

Prescription date: __________________________  Order date: _____________________________________

Discontinuation date: _______________________________________________________________________

Diagnosis requiring medication: ______________________________________________________________

Intended effect of this medication: _____________________________________________

Must this medication be administered during the school day in order to allow the child to attend school or to address the student’s medical condition? __________________________________

 Expected side effects, if any: ______________________________________________________________ 

Time interval for re-evaluation: _____________________________________________________

Other medications student is receiving:  _______________________________________________

__________________________________________     __________________________

Physician's Signature                                                          Date
 

FOR PARENT(S) GUARDIAN(S) OF STUDENTS WHO HAVE ASTHMA:
I authorize the School District and its employees and agents, to allow my child or ward to possess and use his or her asthma medication (1) while in school, (2) while at a school-sponsored activity, (3) while under the supervision of school personnel, or (4) before or after normal school activities, such as while in before-school or after school care on school-operated property.  Illinois law requires the School District to inform parent(s) guardian(s) that it, and its employees and agents, incur no liability, expect for willful and wanton conduct, as a result of any injury arising from a student's self-administration of medication (105 ILCS 5/22-30).
IF YOU AGREE PLEASE INITIAL:                                               ______________________
                                                                                                            Parent(s)/Guardian(s) initial
 

BY SIGNING BELOW, I AGREE:
       I.     That I am primarily responsible for administering medication to my child. However, in the event that I am unable to do so or in the event of a medical emergency, I hereby authorize the School District and it’s employees and agents, in my behalf and stead, to administer or to attempt to administer to my child (or allow my child to self-administer, while under the supervision of the employees and agents of the School District), lawfully prescribed medication in the manner described above.  I ACKNOWLEDGE THAT IT MAY BE NECESSARY FOR THE ADMINISTRATION OF MEDICATION TO MY CHILD TO BE PERFORMED BY AN INDIVIDUAL OTHER THAN A SCHOOL NURSE, AND SPECIFICALLY CONSENT TO SUCH PRACTICES. 
           II.      To indemnify and hold harmless the School District, its employees and agents against any claims, except a claim based on willful and wanton conduct, arising out of the self-administration of medication by the pupil.

 

______________________________________________        ___________________________________________

Parent/Guardian printed name                                                               Parent/Guardian printed name

 

_________________________________            __________________________________
Parent/Guardian signature*                          Date                                 Parent/Guardian signature*                            Date        
*Both parents and/or guardians, if available, should sign.                                                                      Updated September, 2007