EDIT MAIN
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NORTHWOOD SCHOOL DISTRICT
ORDER FOR MEDICATION ADMINISTRATION AT SCHOOL

(Please print or type)

Date order effective to:________________________________________________

School:_____________________________________________________________

Name of student:_____________________________________________________

Physician/Provider:____________________________________________________

Diagnosis:___________________________________________________________

___________________________________________________________________.

Medication/dose/frequency/duration:______________________________________

Medication/dose/frequency/duration:______________________________________

Check one: Short term [ ] Long term [ ]

PRN (as situation demands) Medication:____________________________________

Medication/dose/frequency/duration:_______________________________________

If PRN medication, state condition which medication is to be given:______________

____________________________________________________________________.

NOTE

My signature on this document attests to my willingness and intent to direct and supervise the administration of the medication by non medically trained designees appointed by the school administration for that purpose. I will accept direct communications from them regarding the administration of the medication. This consent is valid for the current school year.

______________________________________ _______________________

Physician signature                                              Date

My signature on this document confirms these medications have been prescribed for my child. I agree to this plan and will supply medications to the school in the pharmacy labeled bottle.

______________________________________ _________________________

Parent signature                                                  Date