Marshfield Public Schools

MARSHFIELD PUBLIC SCHOOLS MARSHFIELD, MASSACHUSETTS 02050

Nurse Leader - Jane Landry, RN 781-319-3814 - FAX: 781-319-3969 Daniel Webster - Nicole Dickinson, RN 781-834-5045 Marshfield High - Marianne Bray, RN 781-834-5050 Eames Way - Susanne Fantasia, RN 781- 834-5090 Furnace Brook - Kathleen Keenan, RN 781-834-5020 South River - Catherine Teal, RN 781- 834-5030 Governor Winslow – Courtney Powers, RN 781-834-5060 Martinson - Carolyn Mudge, RN 781- 834-5025

WRITTEN PARENT / GUARDIAN CONSENT FOR MEDICATION ADMINISTRATION

Name of Student: ______Date of Birth: ______M/F______School: ______Teacher/Grade:______Name of Parent/Guardian:______Address:______Phone # (Home):______(Work)______( Cell)______Other persons, if any, to be notified in case of emergency if parent/guardian is unavailable: Name:______Phone/Cell: ______Relationship: ______My son/daughter/ward is currently receiving the following medications (to be completed if not in violation of confidentiality). Please list all medicines the child is receiving, including those given during the school day.

1. ______2. ______3. ______4. ______My son/daughter/ward is known to have the following allergies:______

Consent 1. I give permission to have the school nurse or school personnel designated by the school nurse to give the following medicine:

______prescribed by ______(Name of Medicine) (Licensed Prescriber) ______for______(Name of Student) *(Diagnosis)

2. YES_____ NO______I give permission for my son/daughter/ward to self-administer medication if the school nurse determines it is safe and appropriate:

3. YES_____ NO ______I give permission to the school nurse to share with appropriate school personnel information relative to the prescribed medicine administration, e.g., adverse side effects, as she/he determines necessary for my son's/daughter's/ward's health and safety. Any restrictions on release ______

(Please note: I understand that I may retrieve the medicine from the school at any time and that the medicine will be destroyed if it is not picked up within one week following termination of the order or one week beyond the close of school.)

Signature of Parent/Guardian______

8/2017 Relationship to Student ______Date______* If not in violation of confidentiality

8/2017