JLCD-F

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Smithfield Public Schools

Medication Authorization

As of July 2014 all medications, including prescription and OTC (over-the-counter) medications require a physician’s signature. Medication orders must be renewed prior to the start of each school year.

Student Name:______________________________________________________________ D.O.B.__________________________________

Address:______________________________________________________________________ Home Phone:__________________________

School: ___________________________________________________________Gr_________ Teacher_________________________________

I understand that special permission is required for the use of medication by students during school hours. I request that my child be given the medication described below:

Medication_______________________________________________________ Daily_______ PRN_____________

Dose________________________Route________________Time________________________Frequency___________

Diagnosis/Reason for Medication_______________________________________________________________________________________

This medication may be:

Self- carried Yes _____ No _____ Self-administered Yes _____ No _____

Side effects_____________________________________________________Allergies________________________________________________

Other information_______________________________________________________________________________________________________

_______________________________________________ _________________________

Parent/Guardian Signature Date

Special Requirements/Field Trip

This medication may be omitted on a field trip or activity away from school Yes____ No ____

If inhaler, this medication may be self-administered Yes _____ No _____

If inhaler, this medication may be self-carried Yes_____ No ______

**With parent and physician approval, a student may be authorized to self-carry and/or self-administer a day’s supply of prescription and/or over-the-counter medication, including a controlled substance, on a field trip. Yes ____ No _____

This medication must be supplied by the parent/guardian and must be stored and transported in a properly labeled container.

______________________________________________________ ______________________

Physician Signature Date

REVISED: June 2015