NORTHWOOD SCHOOL DISTRICT
ORDER FOR MEDICATION ADMINISTRATION AT SCHOOL
(Please print or type)
Date order effective to:________________________________________________
Name of student:_____________________________________________________
Check one: Short term [ ] Long term [ ]
PRN (as situation demands) Medication:____________________________________
If PRN medication, state condition which medication is to be given:______________
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