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Prairie Central CUSD #8 REQUEST FOR MEDICATION SELF-ADMINISTRATION |
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Chatsworth Chenoa Meadowbrook Westview |
Fax#815-635-3429 Fax#815-945-2068 Fax#815-657-8535 Fax#815-692-3726 |
Upper Elementary Junior High High School |
Fax#815-657-8821 Fax#815-657-8660 Fax#815-692-3855 |
| STUDENT NAME: ____________________________________ | DOB:___/___/___ |
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MEDICATION: PRESCRIPTION or NONPRESCRIPTION TO THE LICENSED PRESCRIBER: The following information is needed when it is necessary for a student to receive prescription or nonprescription medication at school: |
| Name of Medication: _________________________________________ Dose: ________________ | |
| Time to be Administered: ___________________________ Route to be Administered: ___________ | |
| Purpose of Medication: ______________________________________________________________ | |
| Possible Side Effects: ________________________________ Termination Date: ______________ | |
| Allergies: _________________________________________________________________________ | |
| Other Medications Currently Being Taken: _______________________________________________ |
| FOR INHALERS ONLY: I CONFIRM THAT THIS STUDENT HAS DEMONSTRATED COMPETENCY IN SELF-ADMINISTRATION OF HIS/HER INHALER _____(Doctor's Initials) |
| Physician's Signature:
__________________________________
__________________________________________________________________________________ Physician's Name Address Ph. Number
ALL MEDICATION MUST BE IN THE ORIGINAL (unopened/sealed) CONTAINER |
| Please refer to the Student
Handbook for medication policy.
I give permission for __________________________________________ to self-administer the medication as listed above. I agree to the terms of the procedure as stated in the Student Handbook. It is understood that in instances where the student self-administers medication, Prairie Central #8, the principal or designee shall not, in any way, be responsible that said student administers the proper medication or dosage. A student who self-administers medication shall be solely responsible for the administration of the proper dosage, and the parents/guardians agree to save and hold harmless, completely release and excuse Prairie Central #8 and its employees and agents of any liability or obligation of any nature in any way related to the District's Medication Policy and Procedure. As Parent/Guardian, I also give my consent for Prairie Central CUSD #8 to communicate with my child's physician regarding the above medication(s). Parent/Guardian Signature: ________________________________________Date: _____________ Note: All children are monitored closely when taking their medication. PC Health Care staff initials:_____________ |
Prairie Central Upper Elementary ~ 312 N. Center Street POB 496 ~ Forrest, IL 61741