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Microsoft word - document

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 _________________________________________

Source: http://www.martinsville.k12.va.us/hr/policies/2012-2013handbook/Medication%20authorization%202012-13.pdf

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