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JLCD-FRM1

Authorization for Dispensing Medication

JLCD-FRM1 

HOPKINTON PUBLIC SCHOOLS 

AUTHORIZATION FOR DISPENSING MEDICATION 

NAME OF STUDENT: ______________________________      GRADE: ________ H.R. ________ 

1. I give permission to have the school nurse give the following medicine _________________________ prescribed by____________________________________ to __________________________________ licensed prescriber name of student 

2. I give permission to the school nurse to share with appropriate school personnel information relative to the prescribed medicine administration. YES______ NO ______

Any restrictions on release _____________________________________________________________ 3. My child is currently receiving the following medications: 1. _________________________________ 2. ________________________ 3. ________________________ 4. __________________________ 

4. Known allergies to food or medication: ___________________________________________________ 

5. I request that my child receive his/her/their medication at school prior to dismissal on early release days: YES ________ NO ________ 

Parent/Guardian Signature ____________________________ Date ____________ Phone ___________ 

************************************************************************************* Physician/Licensed Prescriber: 

I request that my patient receive the following medication: 

Student Name: ______________________________ Diagnosis: _______________________________

Name of Medication ___________________________________________________________________

Prescribed dosage and route of administration: ______________________________________________ 

Time to be taken during school hours: __________________

Expected duration of treatment __________

Possible side effects/adverse reactions: ____________________________________________________ 

If epinephrine, inhaler, insulin or enzymes I recommend that student be allowed to self-administer: YES ___ NO ____ Initials _________ 

Other recommendations: _______________________________________________________________

PHYSICIAN'S/LICENSED PRESCRIBER'S SIGNATURE: _____________________________________

Phone: ______________________________ DATE: _________________________________________ 

* I authorize self administration for overnight field trips: YES ____ NO ____ Initials _____ 8.6.2019