Request and Authorization for Medication/Treatment Form

Parents are requested to give medication at home whenever possible.  Students will not be permitted to take medication while at school unless such medicine is given them by the school district personnel certified to dispense medication, acting under the specific written request of the parent or guardian and under the written instructions of the student’s physician.

 When such a request is made by a parent or guardian, a full release from the responsibilities pertaining to the administration and the consequences of such medications must also be presented to the personnel certified to dispense medication upon written authorization of the parent or guardian.

 No medication except cough drops can be stored in a student’s desk, locker, backpack, or student’s coat/jacket.  If a student demonstrates inappropriate behavior in assuming this responsibility, the parents, and supervising nurse will be contacted.  Medications cannot be sent to the Howard Schools in envelopes, plastic bags, or other non-pharmacy labeled containers.  Prescriptions and non-prescription medications will only be given if it is in the original container and a current authorization is on file at the school.

 If it becomes necessary to administer medication to students during school hours the following regulations will be observed: 

·        A parent/guardian or designated adult must deliver to the school all medications to be administered by school personnel.

·         Prescription medication to be administered must be prescribed by a licensed medical professional to the student and be in the original prescription container with the prescription attached.  Medication improperly packaged or labeled will not be administered.

·        Non-prescription medication must be in the original packaging.  Non-prescription medication improperly packaged or labeled will not be administered.

·         Parents/Guardians must provide the information requested below and sign the form granting the school permission to administer the medication.

I request and authorize officials at Howard School District to supervise the below stated prescribed medication and dosage.

Non-Emergency Medications

There may be times when students would benefit from certain medicines at school to treat non-emergency symptoms such as headache, ear ache, stomach ache, or sore throat.  These are examples of situations that can make it difficult for a student to do his/her best work, yet are not severe enough to send the student home.  This form also gives parents the option of allowing school staff who are trained in medication administration to give medications listed below without calling for permission every time.  Non-pharmacological interventions such as heat, cold, food, fluids, or rest will be attempted first.  Parents will be contacted if medications are being given frequently or trends are noted.  Parents will be contacted to pick up a student if fever is present.

Self-Administered Medical Devices

Your child may be in need of an inhaler, Epi-pen, or other device for emergency use.  If your child uses any device of this nature, please indicate below.  Your signature provides your consent for your child to carry an emergency medical device of this nature. 

By signing the form I (1) understand that medication shall be provided in a bottle labeled by the pharmacy to include student name, physician name, medication and strength, dosage and time the medication is taken, (2) understand that the district’s personnel are rendering a service and will administer the medication only in accordance with the instructions on the label, (3) understand the district and individuals involved will not be liable for any possible adverse effects of the medication, and (4) understand the school may contact the prescribing professional regarding the medication and/or its effects.