The undersigned(s) are the parent(s), guardian(s), or person(s) in charge of _________________ (student’s full legal name), who is in the ______ grade at the _________________________ building in the Spirit Lake Community School District.
It is necessary that the above student receive the following medication(s), at the following frequencies, for the following time period (Attach additional sheets if necessary):
(a) _________________________________________________________________________
(Medication)
_________________________________________________________________________
(Frequency (i.e., once at noon, etc.))
Beginning on ______________________ and continuing through ____________________. (Duration)
_____ I hereby request the Spirit Lake Lake Community School District, or its authorized representative, to administer the above-named medication to my child named above and agree to:
1. Submit this request to the principal or school nurse;
2. Personally ensure that the medication is received by the principal or school nurse administering it in the container in which it was dispensed by the prescribing physician or licensed pharmacist or is in the manufacturer's container;
3. Personally ensure that the container in which the medication is dispensed is marked with the medication name, dosage, interval dosage, and date after which no administration should be given. OR
_____ I hereby authorize my child to self-administer his/her medication as he/she has shown the competency to do so. I hereby agree to:
1. Submit this request to the principal or school nurse;
2. Personally ensure that:
a. the medication is received by the principal or school nurse administering it in the container in which it was dispensed by the prescribing physician or licensed pharmacist or is in the manufacturer's container; or b. the medication will be kept in the student's possession but only with prior written permission from the parent and principal.
3. Personally ensure that the container in which the medication is dispensed is marked with the medication name, dosage, interval dosage, and date after which no administration should be given.
___________________________________ _________________ (Signature of Parent/Guardian) (Date)
___________________________________ (Printed Name of Parent/Guardian) (Phone Number) - ______________________
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Approved: 5/13/13 Reviewed: 6/10/19 Revised: