Independence Community School District
Parental Permission for Administering Medication at School

Student Name ______________________________________ DOB ___________________________

Medication _________________________________________________________________________

Reason for Medication ________________________________________________________________

Dose ______________________________Time to be given ___________________________________

Physician/Prescriber name __________________________________Phone Number ______________

Give on Early Out Days: Yes _______ No ________    Give on Late Start Days: Yes _______ No _______

I request that the medication be administered by a qualified staff person according to the written directions given. I agree that school personnel may contact the prescriber as needed and that medication information may be shared with school personnel who need to know.  I understand the law provides that there shall be no liability for damages as a result of the administration of medication where the person administering the medication acts as an ordinary reasonably prudent person would under the same circumstances and that the school district and the school nurse are to incur no liability, except for gross negligence, as a result of injury arising from the administration of medication. I will comply with the procedure listed on the back of this form related to the administration of medication at school.

Parent/Guardian name ________________________________________________________________

Signature ___________________________________________________________________________

Date__________________________________Home Phone___________________________________

Cell phone _________________________________ Email ____________________________________

MEDICATION WILL NOT BE GIVEN IF IT HAS EXPIRED OR IT HAS AN IMPROPER LABEL. PLEASE CHECK THE CONTAINER BEFORE SENDING IT TO SCHOOL

PERMISSION FOR DISPOSAL OF UNUSED MEDICATION AT THE END OF THE SCHOOL YEAR – Please check one

_____I will pick up any unused medication at the end of the school year.

_____Please send any unused medication home with my child. The school district will not be responsible for the medication once it is in the possession of my child.

Parent/Guardian signature _____________________________________Date ____________________

Independence Community School District
Request to Administer Medication in Schools
Information and Procedures

1. All medications should be taken before or after school hours whenever possible. However, it is understood that certain drugs may be required during the school day. These students should have medication available and administered in a manner which is compliant with school district policy.
2. Medication shall be administered when the student’s parent/guardian provides a signed and dated written statement requesting medication administration and the medication is in the original, labeled container, either as dispensed by the pharmacy or in the manufacturer’s container.
3. Prescription medication: A current pharmacy labeled container can serve as the written prescriber’s order. A second labeled medication container can be obtained free of charge for school use by asking the pharmacist.
4. Over the counter/non-prescription medication will be given only with parent/guardian written authorization. Over-the-counter/non-prescription medications are to be provided by the parent/guardian and sent to school in the original medication container with the student’s name attached. This procedure will safeguard your child against over medicating and possible unforeseen reactions.
5. The parent/guardian is responsible for submitting a new prescriber’s order form to the school each time there is a change of dosage or time of administration. Prescriber’s orders may be faxed to the school.
6. To ensure the safety of all children, we request that a parent or another responsible adult deliver all medications to the health office when possible. If your child brings the medication to school, please place the labeled medication bottle in a sealed envelope with the number of tablets/capsules that are enclosed written on the outside of the envelope.
7. The first dosage of any new prescription should be given at home so the child can be more closely observed for possible side effects and/or adverse reactions.
8. The parent/guardian is responsible for notifying the school nurse when a medication has been discontinued or changed.
9. No medication will be continued beyond the school year in which it is ordered.
10. The Independence Community School District does not assume responsibility for medication not prescribed by a physician/prescriber or medication administered by a student himself/herself.

               Nurse/Appointed Personnel          Nurse/Appointed Personnel          Nurse/Appointed Personnel
               East Elementary                                 West Elementary                              Jr Sr High School 
               319-332-0533                                      319-332-0589                                    319-332-0720