Moore Public Schools
Parent Medication Consent Form
(It is recommended to give medications at home if possible.)
Student: ____________________________ School: ____________________ Teacher: _______________ Gr: ____
If it is necessary that a medication be given during school hours the following regulations must be met:
*Medication must be ordered/advised by a physician/dentist and permission granted for the school staff to
contact the prescribing physician/dentist if necessary regarding this medication.
*Prescription medication must be brought to school in the ORIGINAL container with appropriate label intact.
The label must have the student’s name, name of medication, dosage, and time to be given. IF MEDICATION
IS NOT PROPERLY LABELED, IT WILL NOT BE GIVEN.
*Non-prescription medication must be in the ORIGINAL, UNOPENED container and accompanied by a
physician request and instructions for administration at school. The physician request must include student’s
name, name of medication, dosage, and time to be given.
*Medication cannot and will not be accepted in baggies or envelopes.
*Parent/guardian MUST sign this form, granting designated school employee permission to give the medication
during school or during school-sponsored activities, according to school policy.
*For your child’s safety, the parent/guardian must bring prescription/non-prescription medication to the school,
rather than sending it with the student. At the end of the school year, any remaining medication must be picked up
by the parent/guardian or it will be discarded by the school. The school can not send medications home with
students. Students CANNOT carry medications on their person. The only exceptions are emergency medications
such as rescue inhalers, epi-pens and insulin. These medications must have a medication consent form on file, signed
by a parent/ guardian and a physician, stating the student can carry the medications. It is highly suggested that you
provide a back-up medication to the office.
*By signing this form, the parent with legal custody or guardianship understands that under state law the Board
of Education, the Moore School District, or employees of the District shall not be liable to the student or the
student’s parents or guardian for civil damages for any personal injuries to the student which result from acts or
omissions of school employees in administering the medication.
*The parent/guardian agrees to provide medication and any particulars connected with administering medication
at their own expense.
*The parent/guardian will promptly notify the school of any change in the administration of this medication and
will provide the school with new prescription bottle and physician order. Written or verbal changes from
parent/guardian CANNOT be accepted.
*The parent/guardian will notify the school of any physician change and obtain a new written prescription.
PLEASE FILL OUT THE FOLLOWING. ALL MEDICATIONS MUST HAVE THE FOLLOWING FILLED OUT BY A
PHYSICIAN/NURSE PRACTITIONER/ PHYSICIAN’S ASSISTANT.
This form will only be valid for the current school year. A new form is required yearly.
PLEASE USE A SEPARATE FORM FOR EACH MEDICATION
Medication: ________________________________
Diagnosis:_____________________________________
Trade name or generic
Dosage: ___________________________
Time(s) to be given at school: ___________________________
Method of administration: ORAL __Liquid __Tablet __Inhaler
Drops: __Eye R L
__Ear R L
Topical: __ apply where ___________________________
Other: _________________________________
Effective Dates: From ___/___/_____ to ___/___/_____
Possible side effects: __________________________________________________________________________
If medication is PRN (as needed), please specify: ____________________________________________________
Signs and symptoms
___________________________ Can medication be repeated? ___Yes ___No How many times? _________
Frequency of Administration
__________________________________ ______________________________________ _____________________ __________________
Physician’s Name (Please print)
Physician signature
Physician’s phone
Date
TO BE COMPLETED BY THE PARENT/GUARDIAN:
I have read the procedure for medication administration and I hereby request and authorize Moore Public Schools
personnel to administer this medication as directed. I agree to release, indemnify, and hold harmless Moore Public
Schools and any of their officers, staff members, or agents from lawsuit, claim, demand, or action against them for
administering medication to this student. I understand that permission is granted for exchange of verbal
and/or written communication between the school staff and the prescribing physician/dentist regarding
this medication.
__________________________________
Signature of Legal Parent/Guardian
________________________
Date
Nursing 3/11
CONTRACT FOR EXCEPTION:
TO SELF-ADMINISTER AND RETAIN MEDICATION ON PERSON
*Provisions under 70 O.S. 1984, Section 1-116.3 and the Moore Public Schools Policy #7150 allow a student to self
administer a prescribed asthma, anaphylactic medication or diabetic medication. Approval to self administer
medications must be authorized by the prescribing physician. The parent/ guardian of the student is to provide the
school an emergency supply of the student’s medication.
___I have instructed ________________________________ in the proper use of his/her medication and it is my
professional opinion that this student is capable of self-administration of the medication and should be allowed to
carry and use that medication by himself/herself.
__________________________________________________
Physician signature
_____/______/__________
Date
I understand this request is governed by Moore Public Schools regulations on self-administration of medication and
there are conditions and exceptions to self-administration. I have instructed my child to inform school personnel if
symptoms persist so additional emergency care can be obtained, if needed. I also understand that this permission
may be revoked if my child misuses the medication. I understand that Moore Public Schools, its agents and
employees shall incur no liability for any adverse reaction or injury suffered by this student as a result of selfadministration.
We, the undersigned, absolve the school of any responsibility in safeguarding our child’s medication.
__________________________________________________
____/_____/____________
Signature of Legal Parent/Guardian
Date
Moore Public Schools
MEDICATION RECORD
2014-2015
Student Name__________________________
Medication____________________________
School_______________
Grade_________ Teacher______________
Dosage________ Time________________
(Person administering medication should initial date box and write the time, initials, and signature at bottom of
page required for each person giving mediation)
M
October 2015 Pill Count:
T
W
Th
23
N = No Med
Initials _____
Initials _____
Initials _____
Initials _____
Initials _____
Initials _____
24
F
25
A = Absent
O = No Show
DC = Discontinue
Signature____________________________________
Signature____________________________________
Signature____________________________________
Signature____________________________________
Signature____________________________________
Signature____________________________________
Medication picked up by parent:
Date______________ Parent Signature___________________________________