AUTHORIZATION TO GIVE MEDICATION AT SCHOOL

STUDENT'S NAME: ____________________________________________________________

TEACHER: ___________________________________________________  GRADE:________

    I   hereby   request   that   Fulton   County  Schools,   through  the principal or designee,
supervise/assist in  the administering of  medication to  my child,
________________________________, according to the instructions contained in the statement below.
I understand that:

• Medications (both prescription and non-prescription) must be in the original labeled container (no baggies, foil, etc.).

• Parent/guardian must provide specific instructions, as well as the medication and related equipment to the principal or clinic personnel.

• It will be the responsibility of the parent/guardian to inform the school of any changes. New medication or new doses will not be given unless a new form is completed.

• All medication will be taken directly to the office/clinic by the parent and/or student.

• Unused medication will be disposed of unless picked up within one week after medication is discontinued.

• School employees will not assume any liability for supervising or assisting in the administration of medication.

_________________________________________________________________________________

Circle One: Prescription or Non-prescription (If prescription, have physician/health care provider complete and sign bottom portion).

NAME OF MEDICATION: ________________________________________________________

DOSAGE: ____________________________________________________________________

STOP MEDICATION ON: : ________________________

PHYSICIAN'S NAME: _______________________      PHYSICIAN'S PHONE: ______________

I  release  the  school  board, the  school, and  any school  employee  from any liability for administering this medication.

__________________________________                __________________
     PARENTS/LEGAL GUARDIAN'S SIGNATURE                                  DATE

Home Phone: ____________ Work Phone: ___________  Pager/Cell Phone: _______________

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TO BE COMPLETED BY HEALTH CARE PROVIDER FOR PRESCRIPTION MEDICATIONS

CONDITION/ILLNESS REQUIRING MEDICATION: _________________________________________

POSSIBLE SIDE EFFECTS, IF ANY:    ____________________________________________________

SIGNATURE OF HEALTH CARE PROVIDER:__________________________  DATE: _____________

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To be completed by Clinic Aide/ School Nurse only:

Received Date: ________________  Medicine: ____________________________ # of doses _______