<p> MANITOWOC PUBLIC SCHOOL DISTRICT Consent to Administer Medication</p><p>Student D.O.B. School Grade </p><p>Parent Home # Work/Cell/Pager # </p><p>Prescribing Physician ______MD phone Fax # ______</p><p>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.</p><p>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.</p><p>Name of Drug Dosage Time Route</p><p>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.</p><p>I agree to notify the school in writing at the termination of this request or of any change in medication.</p><p>*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.</p><p>Signature of Parent/Guardian Date</p><p>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.</p><p>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</p><p>2. Under what conditions or schedule the drug should be given and repeated: </p><p>3. Side effects (expected or predicted) </p><p>4. Purpose of the medication </p><p>Medication Route Amount Time Duration of Medication</p><p>Signature of Physician Date</p><p>Questions or concerns regarding this medication’s effects may be directed to the physician at any time.</p><p>H2003 Revised 9/8/11</p><p>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</p><p>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:</p><p>Signature:______Initials:______Date:______</p><p>Signature:______Initials:______Date:______</p><p>School RN:______</p>