Medication Condition for which medication will be required for student in school:

Name of Medication
Prescription:

Over-the-Counter(non-prescription):

Route to administer (select one):
Oral(by mouth)TopicalSubcutaneous(injected)Inhaled(breathed)Other(describe)

Dosage:

Frequency:

Time of Day (ex.11:00 AM):

Is this a new medication?
YesNo
If yes, the first dose must be administered at home.

Prescription medications require healthcare provider signature below:
Physician's orders are required for all prescription medications given at school.

Physician's Name (Print):

Phone Number:

Phone Number:

Physician's Signature:

Date:

Fax Number:

I have prescribed the student to self-carry MDI, pancreatic enzymes, EPI-PEN, or other life saving medications described on this page.

1. I give permission for my child's doctor to be contacted foor information regarding the administration of the medication listed on this form.
2. I authorize the above medication to be administered as described or prescribed during school or after-school programs operated by Collier County Public Schools.

Parent/Guardian Name Printed:

Parent/Guardian Signature:

Date:

Home Phone:

Business Phone:

Emergency Phone Number:

Physician's verbal order obtained:

Date:

Time:

Content of physician's verbal order obtained:

Reviewed by:

Date:

Dear Parent/Legal Guardian:

If your child needs to have medication(s) given during the school day, State Regulations and School Board Policy require that you provide written authorization for all medications to be given. An authorization for prescription medication must also be completed and signed by a physician or other health care provider licensed in the State of Florida (as outlined in Florida Statutes, F.S. 464) Medications not approved by the Food and Drug Administration (FDA) and alternative medications, including natural, herbal remedies, homeopathic medicines, food supplements, and vitamins may not be administered at school, with the exception of prescribed pancreatic enzymes).

• The Medication Authorization Form on the reverse side of this document must be entirely completed and accompany any medication (either prescribed or over-the-counter) to be given to your child in school. The form must be signed by a parent/legal guardian and the prescribing physician/legal-healthcare-provider when indicated. Staff members will not be able to administer medication to your child withoout this written authorization and consent. Thank you for assisting us to provide safe medication administration for your child during the school day.
• A parent/legal guardian or an authorized adult must hand carry medications to the school health room/clinic. At the time of delivery, the quantity of each medication will be verified by school personnel. Do not send medications to school with your child.
• Medications that are to be only one time per day or medications that can be administered before or after school not be administered at school.
• Prescribed medications must be received at school in a container with the original, unaltered prescription label attached. Label must be written in English.The label must display all legal information required for a pharmacist to dispense a prescription medication such as valid issue and expiration dates, the student's name, the medication name, dosage, time to be administered, and the physician/legal-healthcare-provider's name.
• Over-the-Counter (OTC) and FDA approved non-presciption medications must be in the original sealed (unopened) store-issued container. Please also label the container with your child's full name and birth date. OTC's, including cough drops, will only be given according to directions on the label. If a parent/guardian requests dosages or administration recommendations that do not appear on the OTC or non-prescription medication label, orders stating the reason for the administration variation must be obtained by the parent/guardian from the physical/legal-hehalthcare-provider and will be considered by a school nurse before safe administration may occur. Based on the school nurse's assessment, a parent may be required to obtain a physician's authorization for increased and/or daily administration of an OTC medication.
• If your child is authorized to selft-carry and use life saving medications as prescribed by his/her healthcare-provider, the child must demonstrate competency in self-administration/self-treatment and a "Contract for Self-Carried Medication" must also be completed and signed by the parent and school nurse.Medication with current prescription label must be signed-in to school clinic. Please see reverse side of this document for Medication Authorization.