LAFAYETTE SCHOOL DISTRICT

Department of Special Services

Permission to Administer Medication

School Year: ___________ Student Name: _________________________________ School: _____________________________ Medication to be given at school: Medication Dosage Time to be given

Method of Administration

Reason for Medication

Medication given at home: Name of medication:______________________ Dosage: ____________ Time given:____________ Name of medication: ______________________ Dosage: _____________ Time given: ___________ Name of medication: ______________________ Dosage: _____________ Time given: ___________ Name of medication: ______________________ Dosage: _____________ Time given: ___________ Name of medication: ______________________ Dosage: _____________ Time given: ___________ (Please read instructions on back) I request that designated school personnel assist in the administering of my child’s medication as prescribed above. I give my consent for the designated school personnel to communicate with my child’s physician and counsel school personnel on the possible effects of my child’s medication. Signature of Parent/Guardian: _______________________________ Date: ____________________ Name of Physician: _______________________________________ Phone: ___________________

Fax: _____________________

Signature of Physician: __________________________________

Date: ____________________



Form # 26 Revised 08/05

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LAFAYETTE SCHOOL DISTRICT

Department of Special Services

Medications to be Given at School Students who need to receive medications at school must have the following: 1. A signed order from the physician which includes the name of the medication, dosage, and time to be given. Attached form must be returned to: Orders can be mailed, hand delivered, or faxed.

Burton Valley

Happy Valley

Lafayette

Springhill

Stanley Middle



561 Merriewood Dr.

3855 Happy Valley Rd.

950 Moraga Rd.

3301 Springhill Rd.

3455 School Street



FAX 925-284-5891

FAX 925-284-4091

FAX 925-283-4091

FAX 925-283-3675

FAX 925-283-1797

and

2. The medication must be in a labeled container from the pharmacist and

3. If the medication is changed during the school year, a new medication form must be signed, and a new labeled container from the pharmacist must be sent to school and 4. All medications sent to school must be brought to school by the parent and not sent to school with the student. I t is required that the parent or legal guardian fill out the form on the reverse side stating whether or not the child receives regular medication at home in addition to medication the child may receive at school. We also need a written order from the doctor for across the counter medications given to the school such as Tylenol, aspirin, decongestants, etc., which should be kept in the original bottle. If you have any questions, please contact your school principal. The California State Legislature has added the following sections to the Education code: 49480. The parent or legal guardian of any public school pupil on a continuing medication regimen for a nonepisodic condition, shall inform the school nurse or other designed certificated school employee of the medication being taken, the current dosage, and the name of the supervising physician. With the consent of the parent or legal guardian of the pupil, the school nurse may communicate with the physician and may counsel with the school personnel regarding the possible effects of the drug on the child’s physical, intellectual, and social behavior, as well as behavioral signs and symptoms of adverse side effects, omission, or overdose. The superintendent of each school district shall be responsible for informing parents of all pupils of the requirements of this section. 49423. Health Medications During School. “Provides that pupils required to take, during the regular school day, medications prescribed by a physician may be assisted by the school nurse or other designated school personnel if the school district receives specified written statement from such physician and the parent or guardian of the pupil.”

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Form # 26 Revised 08/05