• 4.35F - MEDICATION ADMINISTRATION CONSENT FORM

  • This form is suitable for school year 2026-2027. This consent form must be updated whenever the student's medication order changes and renewed annually, or whenever a student changes schools. Medications, including those for self-administration, must be in their original containers and properly labeled with the student's name, the ordering provider's name, the name of the medication, the dosage, frequency, and instructions for administering the medication (including times Additional information accompanying the medication shall state the purpose for the medication, its possible side effects, and any other pertinent instructions (such as special storage requirements) or warnings.

    I hereby authorize the school nurse or his/her designee to administer the following medications to my child.

  • I acknowledge that the District, its Board of Directors, and its employees shall be immune from civil liability for damages resulting from the administration of medications in accordance with

  • Date*
     / /
    2 digit month, 2 digit day, 4 digit year
  • Is your child in Grades 9-12?*

  • 4.35F2—MEDICATION SELF-ADMINISTRATION CONSENT FORM

  • This form is valid for the 2026-2027 school year. This consent form must be updated
    whenever the student's medication order changes and renewed annually, or whenever a student changes schools.

    The following must be provided for the student to be eligible to self-administer rescue inhalers and/or auto-injectable epinephrine. Eligibility is only valid for this school for the current academic year.

    • a written statement from a licensed health-care provider who has prescriptive privileges that he/he/she has prescribed the rescue inhaler and/or auto-injectable epinephrine for the student and that the student needs to carry the medication on their person due to a medical condition;
    • the specific medications prescribed for the student;
    • an individualized health care plan developed by the prescribing health-care provider containing the treatment plan for managing asthma and/or anaphylaxis episodes of the student and for medication use by the student during school hours; and
    • a statement from the prescribing health-care provider that the student possesses the skill and responsibility necessary to use and administer the asthma inhaler and/or auto-injectable epinephrine.

    If the school nurse is available, the student shall demonstrate his/her skill level in using the rescue inhalers and/or auto-injectable epinephrine to the nurse. Rescue inhalers and/or auto- injectable epinephrine for a student's self-administration shall be supplied by the student's parent or guardian and be in the original container properly labeled with the student's name, the ordering provider's name, the name of the medication, the dosage, frequency, and instructions for the administration of the drug (including times Additional information accompanying the medication shall state the purpose for the medication, its possible side effects, and any other pertinent instructions (such as special storage requirements) or warnings.

    Students who self-carry a rescue inhaler or an epinephrine auto-injector shall also provide the school nurse with a rescue inhaler or an epinephrine auto-injector to be used in emergencies.

    My signature below acknowledges that I understand the District, its Board of Directors, and its employees shall be immune from civil liability for injuries resulting from the self-administration of medications by the student named above.

  • Date*
     / /
    2 digit month, 2 digit day, 4 digit year

  • Thank you for completing this form.  Press the Submit button to complete the submission process.  If you have any questions, you can contact the school nurse or Gwen Jones, District Nurse Liason, 870-633-1464.

  •  
  • Should be Empty: