Get School Medication Form

FREDERICKSBURG AREA UNIFIED SCHOOL MEDICATION REQUEST FORM SERVING City of Fredericksburg Caroline County Culpeper County Faquier County King George County Louisa County Orange County Prince William County Stafford County Spotsylvania County Westmoreland County PURPOSE To allow and instruct school personnel to give medications to students during school hours. This applies to any medication prescription or over the counter. REQUIREMENTS The school assumes no responsibility for non-medically prescribed medication or medication administered by the pupil himself. All medicine taken at school must use this procedure unless given by the parent according to policy. This form must be signed by the prescribing physician the parent and the principal or proper designees. This form must be signed by the prescribing physician the parent and the principal or proper designees. Medication must be in the original container. To be completed by physician Name of Student Date of Birth Name of Medication Dosage and Time Schedule Duration of Treatment Side effects precautions special instructions or other comments Grade Physician Name Physician Address Phone Fax I have examined this student and determined this medicine is necessary during school hours. I consent to exchange information with the physician regarding the medication and treatment. I agree to hold harmless the School Board its officers agents and personnel in the event any portion of the medicine is not dispensed as requested. I agree to abide by the school s policies and procedures regarding medication as stated in other documentation. There may be additional statements requested by the specific school that may be attached to this form. Signature of Parent/Guardian Home Telephone Work Telephone Principal/Designee Signature Cell phone. This applies to any medication prescription or over the counter. REQUIREMENTS The school assumes no responsibility for non-medically prescribed medication or medication administered by the pupil himself* All medicine taken at school must use this procedure unless given by the parent according to policy. This form must be signed by the prescribing physician the parent and the principal or proper designees. Medication must be in the original container. To be completed by physician Name of Student Date of Birth Name of Medication Dosage and Time Schedule Duration of Treatment Side effects precautions special instructions or other comments Grade Physician Name Physician Address Phone Fax I have examined this student and determined this medicine is necessary during school hours. Physician Signature Date I request and authorize school personnel to administer the above medicine to my child. Medication must be in the original container. To be completed by physician Name of Student Date of Birth Name of Medication Dosage and Time Schedule Duration of Treatment Side effects precautions special instructions or other comments Grade Physician Name Physician Address Phone Fax I have examined this student and determined this medicine is necessary during school hours. Physician Signature Date I request and authorize school personnel to administer the above medicine to my child.