Medication Policy and Physician Order Form - Summerville High ...

DORCHESTER SCHOOL DISTRICT TWO
MEDICATION PERMISSION REQUEST FORM
The following is to be completed by a legal prescriber.
Name of Student: __________________________________Grade/Section: _________
This medication is being given for: ___________________________________________
________________________________________________________________________
Name of medication: ______________________________________________________
Dosage: __________________________________
Times to be given at school: ________________________________________________
___________________________________________________________
List any potential reactions with appropriate treatment: ___________________________
________________________________________________________________________
________________________________________________________________________
____________________________________
Legal Prescriber (print name and title)
_________________________________
Signature of legal prescriber
Office Phone #: ______________________________
Fax #: _____________________________________
Date: _____________________
To be completed by parent or legal guardian:
I, the undersigned, ask that the above medication be administered to my child as
directed and hereby release everyone participating in this request from any and all
liability associated therewith or stemming therefrom.
When the school nurse is not available, the school principal’s designee will assist
your son/daughter in taking his/her medication.
Do not bring more than 30 days supply of medication at one time. A parent or
responsible adult, NOT THE STUDENT, must bring in all medications.
I have also read the district policies on the back of this form.
____________________________________________
Signature of Parent/Guardian

YOUR CHILD AND MEDICINE AT SCHOOL
Dorchester School District Two is genuinely concerned with the
health and welfare of your child. Because of this concern, this
district has established rules and consistent procedures for the
proper administration of prescribed medications during school
hours. Consistency is needed due to the variety of student
health problems and a large student population.
GENERAL RULES
A school staff member will assist with the administration of
prescription drugs only upon receipt of the completed
Dorchester School District Two Medication Permission Request
Form (on the reverse side of this page) signed by the
parent/legal guardian and his/her child’s physician or other legal
prescriber.
Students may not have medication in their possession during
school or at school events.
In some rare instances, the school district (after reviewing
individual situations) reserves the right to reject requests for the
administration of any medications.
All medicines should be in original prescription
container.
PARENT RESPONSIBILTY
The school district needs your help with the following
procedures:
a) Deliver the completed Medication Permission Request
Form (see back) and original prescription container to
the school.
b) Inform the school of any changes in the pupil’s health
or medication.
c) Update Medication Form annually or as required (i.e.
change in medication)
d) Pick up any unused medication within one week of
termination of treatment or last day of school for
students, whichever comes first.
e) Be aware that no more than a thirty-day supply of
medication may be kept at school.
f) Be responsible for the medication until the principal or
his or her designee receives it.
d) Destroy medicine one week after termination of
treatment (or as soon as feasible) or end of school year,
if not reclaimed by parents.
We suggest you take the Medication Permission
Request Form to your doctor or clinic to be copied
for future use.
QUESTIONS AND ANSWERS
Q. Can any child take over-the-counter drugs at school
(aspirin, Tylenol, cough syrup, etc.)?
A. No. Your child may be given these medications only
when prescribed by a doctor or other legal prescriber and in
a properly labeled prescription container.
Q. What happens if I forget to send in the Medication
Request Form?
A. The school cannot assist with administration of the
medication without the signed form (or written orders from
a doctor or legal guardian). You may go by the school and
give the school your child’s original prescription medicine
container and the completed form (or order).
Q. Can my child carry his/her medicine at school?
A. No. All medication is required to be kept in a locked
area at the school. Your child’s medication needs to be
immediately given to the principal or the school staff
member responsible for medication.
(Due to a life threatening condition, students may be given
permission to carry their medications. Permission will be
granted only after careful review by the school district in
consultation with the registered professional school nurse and
your child’s doctor)
The first dose of medication should be given at home.
SCHOOL RESPONSIBILITY
a) Receive and review Medication Permission Form and
original prescription container.
b) Designate Registered Nurse/designee to assist with
administration of medication, keep in secured/locked
location, and complete medication log.
c) Communicate with the parent, principal, and the
registered professional school nurse on any problems
or effects of administering the medication.
DORCHESTER SCHOOL DISTRICT TWO
102 Green Wave Boulevard
Summerville, SC 29483
Updated August 2008