NEWBURY LOCAL SCHOOLS

ADMINISTRATION OF MEDICATION PERMISSION FORM

Any medication, including both prescription and non-prescription (over the counter) drugs, must be accompanied by this statement of medication to be administered by school personnel. This statement must be signed by both the student’s parent/guardian and physician and must contain all information requested. Parents should note that no school employee who has been authorized by the Board to administer a drug, and who has a copy of the most recent copy of this form, is liable for administering or failing to administer the drug unless such person acts in a manner which constitutes “gross negligence or wanton or reckless misconduct.”

Student School/Grade

Address City/Zip

Section I - Parent Permission

The responsibility of giving medication at school is a serious one, and it is preferred that medication be given at home whenever possible. If it must be given during school hours, Ohio Law requires:

1. All medication (non-prescription and prescription) must be supplied by the parent or guardian.

2. The original medication container must be labeled with:

A. student’s name

B. name of medication

C. dosage

D. time of administration

I hereby request that the following medication be administered to my child, and I give my permission for the principal or his/her designee to administer the medication listed.

Parent Signature Date

Section II - Physician Permission and Instructions for Administering Prescription or Non-Prescription

Medication

is under my care and should receive

Name of Student

at the following times:

Medication and dosage

Possible side effects/adverse reactions:

Specific Instructions:

Beginning date of this request: Expiration date:

Physician’s Signature

Print Physician’s name

Physician’s phone #

Date