Alabama State Department of Education Revised 09/11/07



    Student’s Name __________________________________________________Date of Birth______________________________

    School ________________________________ Grade __________ Teacher _________________________ School Year ______

    List any known drug allergies/reactions __________________________________Height (inches)_ ______ Weight (lbs) _______


    Name of Medication _____________________________________ Reason for Taking __________________________________

    Dosage _______________ Route ________________________ Frequency/Time(s) to be given ____________________________

    Begin Medication __________________________________ Stop Medication _________________________________________

    Date Date

    Special Instructions:

    Does medication require refrigeration? Yes   No  

    Is the medication a controlled substance? Yes   No  

    Is self-medication permitted and recommended for this student? Yes   No  

    If yes, do you recommend this medication be kept "on person" by the student? Yes   No  

    Potential Side Effects/Contradictions/Adverse Reactions __________________________________________________________

    Treatment Order in the event of an adverse reaction: _____________________________________________________________

    (Attach additional sheet or use the back of this form if necessary)

    I hereby affirm that this student has been instructed in the proper self-administration of the prescribed medication (s).

    ________________________________________ __________________ _____________________ ____________________

    Signature of Prescriber (please print) Date Phone Fax


    I authorize the School Nurse, the registered nurse (RN) or licensed practical nurse (LPN) to delegate to unlicensed school personnel the task of

    assisting my child in taking the above medication. I understand that additional parent/prescriber signed statements will be necessary if the dosage of

    medication is changed. I also authorize the School Nurse to talk with the prescriber or pharmacist should a question come up about the medication.

    Medication must be registered with the principal, his/her designee, or the school nurse. It must be in the original, unopened, sealed container and be

    properly labeled with the student’s name, prescriber’s name, date of prescription, name of medication, dosage, strength, time interval, route of

    administration and the date of drug expiration when appropriate.

    ________________________________________ __________________ _____________________ ____________________

    Signature of Parent Date Phone Cell


    I authorize and recommend self-medication by my child for the above medication. I also affirm that he/she has been instructed in the proper selfadministration

    of the prescribed medication by his/her attending physician. I shall indemnify and hold harmless the school, the agents of the school,

    and the local board of education against any claims that may arise relating to my child’s self-administration of prescribed medication(s).

    ________________________________________ __________________ _____________________ ____________________

    Signature of Parent Date Phone Cell