Prescription Medication - Prescription Medication that is not an Inhaler or Epi-pen
KUTZTOWN AREA SCHOOL DISTRICT
AUTHORIZATION FOR MEDICATION DURING SCHOOL HOURS
Prescription medication must be stored and administered by the school nurse or the principal’s designee except in the case of asthma inhaler or epipen for allergies. ALL medication must be brought to school in the original medication bottle listing: the name of the student, name of the medication, dosage and frequency of administration.
Prescription medicine brought to school that is not properly labeled will not be administered (i.e. plastic bags, in an envelope etc). As per school district policy, all medication must be brought to school by a parent or their designee.
Pennsylvania State law requires a written doctor’s order stating the child’s name, medication to be administered, dose, frequency and route of administration must accompany the medication. A parent signature is also required giving the school permission to administer medication to their child.
The prescribing physician must complete the following:
1) Child’s Name _______________________________________________________________
2) Diagnosis __________________________________________________________________
3) Medication to be administered __________________________________________________
4) Duration of Medication ________________________________________________________
5) Prescribed dosage and time schedule for administration ______________________________
6) Side effects or limitations on activity _____________________________________________
I certify that it is imperative that the medication prescribed above is taken during school hours.
Physicians Signature ______________________________________________ Date ____________
The parent/guardian must complete the following:
I request that Kutztown School District personnel administer this prescribed medication to _____________________________________________________ according to the physicians order above. As parent/guardian of this child, I hereby release the Kutztown Area School District and all of its employees from any and all liability for damages my child may suffer as a result of this request.
Parent/Guardian signature _____________________________________________