Carteret County School Health   

                                                                medications

                                                       CARTERET COUNTY PUBLIC SCHOOLS

                       PHYSICIAN'S AUTHORIZATION FOR MEDICATION

                                             GIVEN DURING SCHOOL HOURS

                              To be completed by physician

                Student ____________ __________ ______School _____ _ __________________________________

                     Medication: ______________________________ Dosage ___________________________________                                    

                     Time(s) medication is to be given: am _________________________________ pm_______________ __                                                                                                              

                     To be given from (date) __________________________ to____________________________________                                                                                                                  

                     Significant Information: (side effects, toxic reactions, omission reactions):_____________________________                                                                                                                                                                                      

                     Contraindications for Administration: ______________________

                     If an emergency situation occurs during the school day or if the student becomes ill, school officials are to:

                     a.Contact me at my office _________________________________________ Tel. Number ___________

                     b.Take child immediately to the emergency room at ____________________________________________

                     c.Other option __________________________________________________ ____:___________ ___ _  

                     __________________________________                       Date:________________________________

             Physician's Signature                                                               DEA # _______________________________  

                    This medication will be furnished by PARENT or GUARDIAN within a container properly labeled by a 

                    PHARMACIST with the identifying information, (e.g., name of child, medication dispensed, dosage prescribed, 

                    and the time it is to be given).  No injection will be given except in extreme emergency, such as aIlergy to.wasp 

                    or bee sting.

                    The above written order will not be changed without a written request provided by the Physician. **************************************************************                                                                                          PARENT'S PERMISSION

                   I hereby give my permission for my child (name above) to receive medication during school hours. I understand   

                   the school  undertakes no responsibility for the administration of the medication. This medication bas been 

                   prescnbed by a licensed physician. I hereby release the School Board and their agents and employees from any 

                   and all liability that may result from my child taking the prescribed medication.

                   Signature of Parent or Guardian ____________________________________________________________

                   Telephone______________________________Date___________________________________________                                                                                                  **************************************************************

                   Reviewed by School Nurse_________________________________Date______________________________