NORTHWOOD SCHOOL DISTRICT
ORDER FOR MEDICATION ADMINISTRATION AT SCHOOL
(Please print or type)
 
 
Date order effective to:________________________________________________
 
School:_____________________________________________________________
 
Name of student:_____________________________________________________
 
Physician/Provider:____________________________________________________
 
Diagnosis:___________________________________________________________
 
___________________________________________________________________.
 
Medication/dose/frequency/duration:______________________________________
 
Medication/dose/frequency/duration:______________________________________
 
Check one: Short term [ ]    Long term [ ]
 
PRN (as situation demands) Medication:____________________________________
 
Medication/dose/frequency/duration:_______________________________________
 
If PRN medication, state condition which medication is to be given:______________
 
____________________________________________________________________.
 
NOTE
 
My signature on this document attests to my willingness and intent to direct and supervise the administration of the medication by non medically trained designees appointed by the school administration for that purpose. I will accept direct communications from them regarding the administration of the medication. This consent is valid for the current school year.
 
______________________________________                 _______________________
Physician signature                                                                     Date
 
My signature on this document confirms these medications have been prescribed for my
child. I agree to this plan and will supply medications to the school in the pharmacy
labeled bottle.
 
______________________________________                 _________________________
Parent signature                                                                          Date