SILVERWOOD SCHOOL
REQUEST FOR MEDICINE AT SCHOOL

PHYSICIAN’S ORDER FOR MEDICINE AT SCHOOL

In order for children to receive medicine while at school, the following form must be complete filled out

and returned to the school.

Request is for the following student:_________________________________________________________

Reason for medication:____________________________________________________________________

Name of medication:______________________________________________________________________

Dosage and mode of administration:__________________________________________________________

Time(s) to be given:_______________________________________________________________________

Inclusive dates during which medication is given:________________________________________________

Side effects of drug to be expected, if any:______________________________________________________

________________________________________________________________________________________

Action required if side effects occur:___________________________________________________________

________________________________________________________________________________________

Name of physician:__________________________________ Phone:______________________________
Please print

Physician Signature:_________________________________________ Date:_________________________

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PARENT’S REQUEST FOR GIVING MEDICINE AT SCHOOL

I request that the principal or a designated staff member give my child, ___________________________________,

the medicine above prescribed by Dr. ______________________.

The medication is to be furnished by me and is to be in the original container from the pharmacy with the label intact.

I understand that my signature on this form constitutes a waiver for any liability that may occur in the administering

of this medicine at school when the medication is administered in accord with the physician’s direction, indicated above.

_____________________________________________________ _______________________________
Signature of parent or guardian Date

This request will expire at the end of the current school year. You may resubmit this request each school year.

STUDENTS

Medication at School

Students shall not take medication in school or at school-sponsored activities without authorization. Authorization shall

consist of the following:

1. Elementary Students/Junior High Students:

a. Prescription and non-prescription medications may be dispensed at school. The decision to dispense

these medications will be determined by the school’s consultant for the medication policy based on

written recommendation from the student’s physician or dentist.

b. In such cases, procedure for dispensing medication will be followed.

2. High School Students:

a. Prescription and non-prescription medications may be self-administered if authorized by written

parental permission on file at the school.

b. In such case, procedure for self-administered medication will be followed.

Legal Reference: RCW 28A.31.150 Administration of Oral Medication by Conditions

RCW 28A.31.155 Administration of Oral Medication by Immunity from Liability

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Dispensed Medications

In order to protect both the student and the school, the following procedure will be established:

1. No medication will be given at school until physician/dentist REQUEST FOR MEDICINE AT SCHOOL and

PARENTS REQUEST FOR GIVING MEDICINE AT SCHOOL have been completed.

2. The forms will be referred to the consultant who may review the request with the physician/dentist prescribing the medicine.

3. The Head of School will designate which office personnel will dispense the medications.

4. The consultant will inform the designated office personnel regarding the medication use and its side effects and the safe

keeping of medication.

5. The parent will bring to school the completed form and the medication in the original container that is well labeled and

containing only the required number of doses. The parent may want to obtain two bottles from the pharmacist when

purchasing medication.

6. The office personnel will record the name, the date, the amount and the hour for each medication given on the

medication record.

7. Upon completion of the medication schedule, or at the end of the school year, the permissions form and medication record

will be filed in the student’s health record.

8. Medication remaining at the end of the school year will be discarded unless it is picked up by the parent within five (5) days.

Medication will not be sent home with the student.

9. Medications refer to prescription, as well as over-the-counter medication.

Parents who send medications and notes to the teacher requesting that the school dispense pills, must be contacted.

The Head of School, or designee, will make this contact and review the policy that NO MEDICATIONS will be given at

school until this form is completed and presented to the school.

September 2008