School Health Services
Dillon School District Four
401 E. Third Ave.
Lake View, SC 29563
Julia Pittman, RN
Telephone: (843) 759-3009
FAX: (843) 759-3015
MEDICATION PRESCRIPTIVE FORM
Lake View High School
Dear Parent:
Dillon School District Four recommends that parents administer all medications to students at home.
However, there are occasions when a child is required to take oral medication during school hours and a parent
cannot be at school to administer the medication. In such cases the student may be assisted by school personnel
as designated by the principal since the schools do not have a nurse present on campus at all times.
For students in grades 6 and under, medication must be transported to and from school by a parent. All
medications must be brought in the original container and will be stored under lock and key. (Exceptions include
emergency beesting kits, Epipens, and inhalers. These may be brought and kept by students for emergency use
with proper authorization and documentation of competency to self administer by the parent and physician.)
Parents must assume responsibility for informing appropriate school personnel of any change in
the child’s health status as well as any side effects, dosage change, or discontinuation of the medication. A
new form is required each school year and also for any changes in dosage or time of administration. A separate
form is required for each medication. Please note that the school district retains the discretion to reject requests
for administering medication.
PLEASE BE SURE ALL INFORMATION AND SIGNATURES ARE PROVIDED.
TO BE COMPLETED BY PARENT:
I request that the principal’s designee assist my child
(Child’s Name)
with the medication listed below as prescribed by
.
(Physician’s Name)
Signature of Parent
Date
Home Phone
Work Phone
If self administering, I certify that my child is competent.
Initial
TO BE COMPLETED BY PHYSICIAN:
Name of prescribed medication:
(1)Dosage:
Time(s):__________ (2)Dosage:___________Time(s):
For the time period from:
to
month
day
____________________________
year
month
Purpose:
Possible Side Effects:
Signature of Physician
Date
day
year