Student Name (print): CASCADE SCHOOL DISTRICT #5 10226 Marion Rd SE; Turner, OR 97392

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Self-Medication Agreement In accordance with OAR 581-021-0037 and following age appropriate guidelines: Grades K-8:

Self-medication of prescription and nonprescription medication is NOT allowed EXCEPT in cases where a student must carry such medication on his/her person for immediate access and subject to the stipulations below.

Grades 9-12:

Self-medication of prescription and nonprescription medication (with the exception of sedatives, stimulants, anti-convulsants, narcotics, analgesics or psychotropic medications) may be allowed subject to the stipulations below.

1.

A permission form must be submitted for self-medication for all prescription medication and signed by the physician, parent, student, building administrator and district nurse.

2.

A permission form must be submitted for self medication for all nonprescription medication and signed by the parent, student, building administrator and district nurse.

3.

All prescription and nonprescription medication must be kept in its appropriately labeled, original container, as follows:  

Prescription labels must specify the name of the student, name of the medication, dosage, route, and frequency or time of administration and any other special instructions. Nonprescription medication must have the student’s name affixed to the original container.

4.

The student may have in his possession only the amount of medication needed for that school day.

5.

Sharing and/or borrowing of medication with another student is strictly prohibited.

6.

Permission to self-medicate may be revoked if student violates school district policy governing administration of non-injectable medication and/or these regulations. Additionally, students may be subject to discipline, up to and including expulsion, as appropriate.

Reference: Policy JHCD

All medication(s) MUST be listed on the other side.

OVER 

Prescription Medications: Medication

Physician Signature

Parent Signature

Student Signature

Building Admin Sign.

District Nurse Sign.

Over the Counter Medications: Medication

Parent Signature

Student Signature

Building Admin Sign.

District Nurse Sign.