Martinsville City Public Schools Authorization for Medication to be Administered During School Hours
(Pharmacy-labeled or original manufacturer containers only)
School ___________________________________ Grade/Teacher ______________________________ Child’s Name _________________________________ Male/Female Date of Birth _______________ Physician’s Name ______________________________________________________________________ Address ______________________________________________________________________________ _____________________________________________________________________________________ To be completed by the PARENT or LEGAL GUARDIAN:
I hereby consent that authorized school personnel administer my child the medication ordered below by the prescribing physician, physician assistant, or nurse practitioner in accordance with Martinsville School Board policy. Date __________________ Parent or Legal Guardian Signature ________________________________ Home Phone _____________ Emergency Phone(s) __________________________________________ To be completed by the PHYSICIAN: Diagnosis for which medication is given: ___________________________________________________ Name of Medicine ________________________ Dosage _____________________________________ Method of administration _______________________________________________________________ If medicine is to be given daily, at what time? _______________________________________________ If there is any reason why the medication must be given at a specific time and not the present standard flexibility of ½ hour please specify. _______________________________________________________ If medicine is to be given “when needed” describe indications: ____________________________________________________________________________________ How soon can it be repeated? ____________________________________________________________ List significant side effects. _____________________________________________________________ Length of time this is ordered. ___________________________________________________________ *Is child authorized to medicate him/herself? _____________________________________________ (Self-medication applies only to asthma medications and auto-injectable epinephrine in accordance with School Board policy.) *Note: In the event a School Nurse is not present when your child may incur an identified acute allergic reaction, his/her Epi-pen/Epi-pen Jr. will be immediately administered by an adult present. The 911 EMS system will also be initiated at this time. It is not possible to follow a medication administration order prescribing Benadryl (diphenhydramine) prior to Epi-pen by anyone other than a School Nurse or trained school personnel.
Date _______________ Physician’s Signature _____________________________________________ Date _______________ Received by School Nurse _________________________________________
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