JLCD-E ©

EXHIBIT

MEDICINES / ADMINISTERING 
MEDICINES  TO  STUDENTS

REQUEST FOR GIVING MEDICINE AT SCHOOL

Name __________________________________  Grade _______________

Teacher ________________________________  School _______________

Medication ____________________________________________________

Diagnosis/reason for giving _______________________________________

Time to be given ____________ a.m.   Time to be given ____________ p.m.

Dates from    ________________________ to ________________________

Prescription medication must be in the original container as prepared by a pharmacist and labeled, including the patient name, name of medication, dosage, and time to be given.  An over-the-counter medication must be in the original packaging, with all directions, dosages, compound contents, and proportions clearly marked.  Student misuse of medication being self-administered may result in seizure and disciplinary action.

______________________________________     ____________________
           Parent's or Guardian's Signature                                  Date

A signed physician's statement indicating the necessity must accompany any request for self-administration of medicine, whether it is prescription or over-the-counter medicine except in the case of medication for diagnosed anaphylaxis including auto-injectable epinephrine and breathing disorders requiring handheld inhaler devices.  In these cases the student's name on the prescription label is sufficient for the physician's recommendation.