Medication authorization form

Milne/Kelvin Grove School District 91
Please Note: Only one medication per form.
(All information in this section must be completed)

STUDENT NAME________________________________ Date of Birth _________Grade _____
ALLERGIES (Please List)_________________________ Current weight of Student_________
Purpose of Medication __________________________________________________________

(Includes, Cough Drops, Tylenol, Motrin, Oragel, Lotions, Mucinex, etc.) Physicians signature is not required for Over The Counter Medications (All information in this section must be completed)
Name of Medication ____________________Strength of Medication_____________ Time to be administered______________ Dose to be administered____________ Special Instructions___________________________________________________ PRESCRIPTION MEDICATION
(Includes all medication ordered by a Physician) Requires a Physician Signature
(All information in this section must be completed)
Name of Medication ____________________Strength of Medication_____________
Dose_____________________ Route________ Frequency____________________
Possible side effects___________________________________________________
Special Instructions___________________________________________________

Physician Signature ________________________________Date______________
Address __________________________________________Phone______________

Parent Authorization

I hereby grant my permission for non-medical support staff of Milne-Kelvin Grove School District to
give (student name)________________________ the above named medication as prescribed. I agree
to provide medication in the original bottle which is properly labeled by the pharmacy/store. The
medication will be kept in the school office. The student will report to the school office to receive the
medication. I am aware that students are not allowed, under any circumstances to have medications
in their possession on school property.
Parent/Guardian Signature_________________________________ Date_________________
Address_________________________________________________ Phone________________
KC 11/09

The purpose of administering medications in school is to help each child maintain an optimal state of health that may enhance his/her educational plan. The medications shall be those required during school hours that are necessary to provide the student access to the educational program. The intent of these guidelines is to reduce the number of medications given in school, yet assure safe administration of medications for those children who require them. GUIDELINES
All prescription medications given in school must be prescribed by a doctor. A written order from the prescribing doctor must be provided and name of the medicine, dosage and time intervals that the medicine is to be taken should also be included. Any over-the-counter medication needs the parent authorization completed and on file at school. (see other side for authorization) Medication must be brought to school in the original package or appropriately labeled container. Over-the-counter medication shall be brought in with the manufacturer’s original label and the child’s name affixed to the container. Written parent/guardian consent is to be placed on file requesting that the medication be given during school hours. Any questions regarding these guidelines can be made by contacting Milne Grove School at 838-0542 or Kelvin Grove School at 838-0737.



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