Wautoma Area School District
Approved 9/28/1989
Revised 03/13/2003
STUDENT INFORMATION – to be completed by District Nurse
Student’s Name:
Grade:
School:
Address:
Date of Birth:
Parent/Legal Guardian:
Phone Number:
MEDICAL ORDER – to be completed by Practioner. Not required for over-the-counter medication.
Please return to Wautoma Area School District, PO Box 870, Wautoma WI 54982-0870
Medication:
Dose and Route:
Hour(s) to be Given:
Diagnosis/Reason for Medication:
Order Valid Until:
Please contact me if the following conditions or reactions to the medication occurs:
I agree to retain the power to direct, supervise, decide, inspect, and oversee the administration of such medication.
Direct contact shall be made with me at anytime should you have any questions.
Practitioner’s Name please print
Practitioner’s Signature
Date
GUIDELINES FOR ADMINISTRATION OF MEDICATION IN SCHOOL
1. A written request as stated on this form must be received from the practitioner AND parent/legal guardian before medication is administered at school.
2. The practitioner must notify the school in writing when the medication is stopped or when any change in the order is necessary.
3. Medication to be administered must have the student’s name, name of the medication and dosage, time to be given, practitioner’s name and contact number, and dispensing pharmacy and contact number printed on the container.
4. Medication that may lawfully be sold over-the-counter (cough medicine, acetaminophen, aspirin, etc.) require written instruction and consent from the parent/legal guardian. Practitioner instructions are not required.
I hereby give permission to school personnel to administer medication to my child according to the above directions and to contact the practitioner if needed. I agree to hold the Wautoma Area School district and designated school employees harmless in any and all claims arising from the administration of this medication at school.
Signature of Parent/Legal Guardian
Date
I hereby give permission for my child to carry his/her emergency medication (i.e. Epi pen, inhaler) on their person.
Signature of Parent/Legal Guardian Date
