St. Thomas More St. Thomas More Catholic Catholic ... - Chapel Hill

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St. Thomas More Catholic. Catholic. Catholic School. Chapel Hill, North Carolina. Request for Prescription Medication to be Given during School Hours.

St. Thomas More Catholic School Chapel Hill, North Carolina Request for Prescription Medication to be Given during School Hours (to be completed by physician) Student __________________________________________ Date of Birth _________________ Medication _________________________________________ Dosage ____________________ (No injection will be given except in extreme emergency, such as allergy to wasp or bee sting.) Time(s) medication is to be given: _________________a.m. ______________ p.m. To be given from (dates): ____________________to ____________________ Significant information (include side effects, toxic reactions, and omission reactions): _______ _____________________________________________________________________________ Contraindications for administration: ______________________________________________ _____________________________________________________________________________ If an emergency situation occurs during the school day or if the student becomes ill, school officials are to: ____ Contact me at my office _______________________ Phone __________________ ____ Take child immediately to the emergency room at __________________________ ____ Other option: _______________________________________________________ This medication will be furnished by parent/guardian within a container properly labeled by a pharmacist with identifying information (e.g. name of child, medication dispensed, dosage prescribed, and the time it is to be given). Physician’s signature ___________________________________ Date ____________________ DEA # _____________________

To be completed by parent I hereby give my permission for my child (named above) to receive medication during school hours. I understand that the school undertakes no responsibility for the administration of the medication. This medication has been prescribed by a licensed physician. I hereby release the School Board and their agents and employee from any and all liability that may result from by child taking the prescribed medication. Signature of parent/guardian _______________________________ Date ________________ Telephone ______________________________Cell __________________________________

To be completed by school Name of person to administer medication ______________________________ Title _____________ Approved by __________________________________, Principal Date __________________

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