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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
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