Denton Independent School District
Parent/Physician Request for Administration of Medication by School Personnel, School Year 2009-10
Parents have the primary responsibility of giving medicine to their child at school, and may come to school to give medicine at any time, after checking in at the school office.
Requests for the administration of medications by school personnel may be made as follows: ( in accordance with Texas Education Code 22:052 and Policy FFAC Local)
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A separate request form is to be completed for each medication, and a new request made for each change in medicines or dosages.
Only those medications that cannot be given outside school hours will be administered. Most three times a day medicines can be given before and after school.
(Prescriptions can be written so that doses are not necessary during school hours. Please discuss this with your doctor)
Elementary students will be given non-prescription, over-the-counter (OTC) medicine by school personnel only with a doctor’s prescription. The doctor may sign this medication sheet or
send written or faxed instruction for administration to the school nurse. Elementary students must come to the health room to receive all their medications with exception* noted below.
Middle school students may, with their parents’ permission (doctor’s order not required) carry small amounts (no more than two days’ supply) of OTC medicine for self-administration; this
medicine must be in the original container labeled with the student’s name, and may not be shared with other students. Middle school students must come to the health room for prescription
medications with exception* noted below. Please encourage your child to take the responsibility to go to the office at the prescribed time.
High school students self-carry and self-administer all their own medications. They may carry only the day’s dose of prescription medicine, it must be labeled in the original container.
No dietary supplements, herbal remedies, vitamins, performance boosters, etc. are allowed on school campuses or at school activities. Exceptions to this practice are rare, and will be made
in writing only after discussion and agreement with the student’s doctor, parents, and school nurse. Any medicine in other than the original container labeled with the student’s name is
considered contraband, subjecting the student to disciplinary measures. Students may never share medications with other students.
All medication must be in the original, properly labeled container, accompanied by this completed form. Please ask your pharmacist to dispense two labeled bottles of medication: one for
home and one for school. Changes in dosages require new labels and new parent request forms; if labels and parent request forms do not match, medication will not be given.
*Exception - Elementary and Middle School students may self-carry and self-administer medication for anaphylaxis (severe allergic reaction) and/or inhalers (prescription and OTC) if: a
doctor has ordered it, the parent has requested it in writing, and the student can demonstrate to the school nurse he/she can take it safely. The inhaler and/or epi pen must be labeled with the
child’s name and the prescription dosage.
At the end of the school year, unused medication that has not been picked up by parents/guardians will be discarded.
For safety reasons, NO first doses of ANY medicine will be administered at school. All information below must be completed and form signed before any medication will
be given by school personnel.
Date of Request_________________________________ Medication to be given from (start date)________________________until (end date)____________________________
Student’s Name__________________________________________________ Grade_________________ Teacher or Team # ________________________________________
Name of Medication ________________________________ Exact dosage (in mg,puffs,etc.) _________________________ Time(s) to be given at school __________________
Reason this medicine is required (for what condition?) and any special instructions, precautions, or side effects______________________________________________________
________________________________________________________________________________________________________________________________________________
If the above medication is to be given on an “as-needed” basis, the following* information must also be provided.
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*Indicate shortest intervals between doses ___________________________*Maximum number of doses during school day________________________
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*Signs and /or symptoms for which the medicine is to be given ________________________________________________________________________
Physician’s Name __________________________________________________ Office Phone _____________________________
Fax ______________________________
I, the undersigned parent/guardian of _________________________________________________________________ request the above medication be administered to my child.
(Student’s Name)
I also give permission to my child’s teacher to administer this same
medication as prescribed above on field trips during this school year.
Signature ______________________________________________________________
Parent/Guardian
__________________________________/____________________________
Home Phone
Work or cell
**Signature _____________________________________________________________
Physician **(A properly labeled prescription container will be accepted as proof of physician’s order)