MANITOWOC PUBLIC SCHOOL DISTRICT Consent to Administer Medication

Student D.O.B. School Grade

Parent Home # Work/Cell/Pager #

Prescribing Physician ______MD phone Fax # ______

The Manitowoc Public School District is required to have written parental/guardian consent for all medication given during the school day, field trips and other school sponsored events. Prescription medication requires physician directions and signature.

PARENT I request that my child receive the following medication administered by appropriately trained school personnel as authorized by myself, parent (and my physician if prescription). Specific questions/concerns may be communicated to the physician by the registered nurse(RN) serving the school district.

Name of Drug Dosage Time Route

I further agree to hold the Manitowoc Public School District and all employees harmless in any and all claims arising from the administration of this medication at school.

I agree to notify the school in writing at the termination of this request or of any change in medication.

*It is highly recommended that medication be transported to school by the parent. According to school policy, all prescription medications must be in a properly labeled pharmacy bottle and over the counter medications must be in their original containers.

Signature of Parent/Guardian Date

NOTE: Any change in medication will require a new form. For year-long medications, consent to administer will expire at the end of each school year. ****Parents are required to pick up all medication at school when discontinued or end of school year. Medication left 3 weeks after this time will be properly disposed of via the medication disposal program in Manitowoc County.

PHYSICIAN: (for prescription drugs only) The following is to be completed by the child’s physician prior to administration at school. 1. Is the medication a PRN drug? YES NO

2. Under what conditions or schedule the drug should be given and repeated:

3. Side effects (expected or predicted)

4. Purpose of the medication

Medication Route Amount Time Duration of Medication

Signature of Physician Date

Questions or concerns regarding this medication’s effects may be directed to the physician at any time.

H2003 Revised 9/8/11

AS NEEDED (PRN) DOCUMENTATION OF MEDICATION CONSENT TO ADMINISTER MUST BE COMPLETED ON REVERSE SIDE BEFORE DISPENSING SEPT OCT NOV DEC JAN FEB MAR APR MAY JUN

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 SCHOOL YEAR: NAME OF STUDENT:

Signature:______Initials:______Date:______

Signature:______Initials:______Date:______

School RN:______