Chapelhillacademy.net

CHAPEL HILL ACADEMY
MEDICATION ADMINISTRATION PERMISSION FORM
YEARLY RENEWAL
If your physician decided it is necessary for your child to receive medication during the school day, please
complete the permission slip below and have your physician fill out the medication information. The
medication must be brought to school on your child’s first day, in the original bottle with the prescription
label intact. All medication forms must be returned in order to administer any medication to your
child. Some of our students need their medication in order to perform to the best of their ability.
Medication can only be administered with the appropriate paperwork completed and returned to school.
Please feel free to contact the school nurse at 973-686-0004 if you have any questions.
INFORMATION MUST BE COMPLETED BY PHYSICIAN:

Name of Student: __________________________________Date of Order: _________________
Name of Medication: _______________________________Dose: _______________________
Time and Circumstances of Administration at School: __________________________________
Name of Medication: _______________________________Dose: _______________________
Time and Circumstances of Administration at School: __________________________________
Name of Medication: _______________________________Dose: _______________________
Time and Circumstances of Administration at School: __________________________________
Diagnosis: ____________________________________________________________________
Medication can be omitted on: Half Days: Yes ____ No ____; Field Trips: Yes ____ No ____
Physician Name & Phone Number: _________________________________________________
Physician’s Signature ___________________________ Please place Physician’s stamp here:
PARENT PERMISSION SLIP
I give permission for (name of child) ________________________to receive the above described medication at school according to school policy. School policy requires that medication be brought in the original container with a pharmaceutical label indicating the name of patient, name of prescription, dosage, time, physician's name, and the date the prescription was issued. I understand that Chapel Hill Academy and its employees shall incur no liability as a result of any injury arising from the administration of the above prescribed medication to my child. I indemnify and hold harmless Chapel Hill Academy and its employees against any claims arising out of the medication, or lack thereof, of my child. Date __________________ Guardian Signature ____________________ Relationship ______________ Phone __________________________ Print Name _____________________________________ PLEASE COMPLETE REVERSE SIDE OF SHEET
CHAPEL HILL ACADEMY
PERMISSION FOR (OTC) OVER THE COUNTER MEDICATION
TO BE ADMINISTERED BY THE SCHOOL NURSE
PARENTAL PERMISSION: I request that my child _____________________________ be administered the following OTC medications by the school nurse:
MEDICATION:
Tylenol Junior ( 160 mgs/tab) ________tablets Tylenol Regular (325mgs/tab) ________tablets Children’s Motrin (100 mgs) ________tablets Children’s Motrin (100 mgs/5 ml) ________teaspoon Advil (200mgs) ________tablets Benadryl (12.5 mgs) ________teaspoon Benadryl (25 mgs) ________tablets Other: FREQUENCY:__________________________________________________________
REASON FOR USE:_____________________________________________________
DATE:__________ Parent/Guardian Signature:________________________________
Permission for medication is effective only for the current school year and needs to
be renewed for each subsequent year.
PHYSICIAN PERMISSION:
I hereby authorize the school nurse to administer the above OTC medications.
_____________________
MD SIGNATURE
ADDRESS/PHONE

Source: http://www.chapelhillacademy.net/uploads/hr_pf_nurse/Medication_Administration_-_Permission_Form.pdf