Microsoft word - medication authorization form page 2 form 2008.doc

Dear Parent or Guardian,
The Hinsdale Township High School District 86 policy regarding the
administration of medication to students is in compliance with Illinois
laws and designed to safeguard all students. Parents have the primary
responsibility for the administration of medication to their children. The
administration of medication to students during school hours is
discouraged unless necessary for the critical health and well-being of the
student.
If a student requires any prescription or nonprescription medication,
including Tylenol and ibuprofen, during the school day, a Medication
Authorization Form must be completed by both the attending
physician and the parent or guardian. This form must be completed
annually. Please use the form on the reverse side.
Prescription medication brought to school must be in a current pharmacy
labeled container. Non-prescription or over-the-counter medication must
be in the manufacturer’s original package and labeled with the student’s
name. Health Services will supply generic Tylenol (acetaminophen) and
generic Advil or Motrin (ibuprofen).
If medication is not required during school hours, disregard the form on
the reverse side. Please contact me at 570-8595 with any concerns.
Sincerely,
Constance Dolan RN IL CSN
Health Services
MEDICATION AUTHORIZATION FORM

Student Name: _______________________________________ Class/ID: __________ /_________________
TO BE COMPLETED BY THE PHYSICIAN: (please print)
All medication (prescription or nonprescription, including generic Tylenol and ibuprofen) requires annual authorization. It is the
parent’s responsibility to update student health information in the event of any change.
Please note: Only generic Tylenol, Advil, or Motrin will be dispensed in the Health Office. If non generic is
ordered, parent must supply the medication. If medication below is not advised, delete or amend as needed.
Medication Required during School Dosage/Route Time and Frequency
Generic Tylenol 325-650 mg po every 4-6 hours as needed
Ibuprofen 200-400 mg po every 4-6 hours as needed
Other Medication Required during School Dosage Time and Frequency
_________________________________________________________________________________________ _________________________________________________________________________________________ Diagnosis requiring medication(s): _____________________________________________________________ Intended effect/Possible side effects: ____________________________________________________________ Other medication student is taking: _____________________________________________________________ Medication student may carry and self-administer: Inhaler, Epi-Pen or insulin (circle if applicable).
Please contact the school nurse at 630-570-8595 for details.
Self-Administered Medication: such as medication for asthma, diabetes, severe allergy or other specified
condition: I or a member of my staff has instructed the above student in the proper administration of the self-
administered medication. He/she understands the need for the medication, the appropriate response, and the
necessity to report to school personnel any unusual side effects or lack of appropriate response. The student is
capable of using this medication independently.
Physician’s Signature ________________________________________________ Date __________________
Physician’s Name ___________________________________ Phone_______________ Fax______________

Parent/Guardian’s Authorization By signing below:
I hereby acknowledge that I am primarily responsible for administering medication to my child. However, in
the event that I am unable to do so or in the event of a medical emergency, I hereby authorize Hinsdale
Township High School District 86 and it employees and agents, on my behalf and stead, to administer or
attempt to administer to my child (or allow my child to self-administer) the lawfully prescribed medication in
the manner described above. I acknowledge that it may be necessary for the administration of medications to
my child to be performed by an individual other than the school nurse, and specifically consent to such
practices. I further acknowledge and agree that, when lawfully prescribed medication is so administered or
attempted to be administered, I waive any claims I might have against the School District, its employees and
agents arising out of the administration of said medication. In addition I agree to hold harmless and indemnify
the School District, its employees and agents, either jointly or severally, from any and all claims, damages, and
causes of action or injuries, except a claim based on willful and wanton conduct, incurred or resulting from the
administration or self-administration of medication.
Parent/Guardian’s Signature ______________________________________________ Date _____________
Address ________________________________________________________________ Phone ____________

Source: http://central.hinsdale86.org/Health_Services/Documents/Medication%20Authorization%20Form.pdf