Medication Permission Form
Allen ISD policy
concerning children taking medicine at school is as follows:
Ø All medications must be dispensed from
the nurse’s office. Do not send medicine for your child to
self-administer. It is a violation of
school policy.
Ø All medications must be in its original
container or they will not be accepted. NO BAGGIES.
Ø The school cannot provide medication. Please send a small amount of medication for
your child. Individual dose packs are
preferred.
Ø PLEASE CHECK THE EXPIRATION DATE OF
THE MEDICINE. We cannot administer
expired medicine to students.
Ø No student should be
carrying an inhaler without a Student Asthma Action Plan which has been signed by your doctor and is
on file in the clinic. Please ask the
nurse for the necessary paperwork.
This
policy is designed for the safety of all Allen students. Thank you for your cooperation.
q None
q Yes,
to:_____________________________________ _________________
Parent’s/Guardian’s name:______________________________________________________________
Phone # where parent can be reached during school hours: __________________________________
For
Clinic Use Only: q
Checked
in and logged q
Counted___________#
pills (count controlled substances only,
not Tylenol, etc.) q
Exp.
Date___________ Received
by: _______________________________
Name of Medication: ________________________________________
Amount of medication to give:
_________________________________
How often to give medication:
q Daily
at _________________(time)
q As
needed every __________hours
q Only
on the following dates: _______, _______, _______, ________
Route of medication administration:
q Oral
q Inhalation
q Sublingual
(under the tongue)
q Topical
(placed on the skin, in eyes, etc.)
q Other
Condition for which drug
is being administered:_____________________________________
Parent/Guardian signature: _____________________________
MED/A8/02