Loading...

Editing previous response:

Please fix the highlighted areas below before submitting.

Consent for Medication Administration Form

Please complete the form below. Required fields marked with an asterisk *

Faulkton Area Schools District 24—4                                                                 District Code: JHCD-E1

Consent for Medication Administration Form

I authorize UMAs (unlicensed medication aides) to administer the following:*
Answer required for "I authorize UMAs (unlicensed medication aides) to administer the following:"

Prescription Medications:  Prescribed medication must be in the original container with pharmacy label.

Over-the-counter medications: The Main Office will have a limited stock of over-the-counter medications on-hand to administer to students who have a signed Consent for Administration form.  The medications on-hand will be Ibuprofen, Acetaminophen, Antacids (Calcium Carbonate) and Cough Drops.  All other over-the-counter medications will need to be supplied by the parent or guardian in the original container.  Dosage will be calculated by the dose recommendations already labeled on the medication according to the student’s weight and age.  I understand generic equivalent medications may be used.

First Dose:  The first dose of any medication must be given by parent/guardian or registered nurse.

Natural Remedies:  Herbs, vitamins, oils, dietary supplements, and homeopathic medications will require a physician’s order or doctor’s note.

Storage/Disposal: Medication stored at school will be kept in a locked cabinet or container.  Parent/guardian is responsible to drop off and pick up medications.  Medication not picked up by the parent/guardian will be destroyed at the end of the school year.  If a parent/guardian is unable to transport medication to and from school, the Superintendent must be contacted regarding alternate arrangements.

I absolve the school personnel of all responsibility for any unforeseen developmental/reaction due to the administration of the above-named medication.  I hereby give consent for the school officials to communicate with my student’s prescribing provider as needed regarding this medication.   

Revised: October/2023

Parent/Guardian Signature:*
Signature Required

Sign this form

By pressing “Sign Form,” you are agreeing to signing this form electronically.
Signature *
Type to sign
Draw your signature

Date:
Confirmation Email