For school year 20____to 20____

NORTH HILLS SCHOOL DISTRICT

Procedure for Administering Medication at School

It is required by the North Hills School District that the attending physician complete this form for any medication to be given during school hours. This form is only good for the school year in which it is signed. All medication must be sent to school in the original container bearing the medication name and, if prescription, the current dose.

________________________________________ Student Name

_____________ Grade

_______________ Date

Medication and Dosage

_______________________________________ Time to be administered

________________to_________________ Duration of the medication course

___________________________________________________________________________________ Condition for which medication is prescribed

___________________________________________________________________________________ Possible side effects

______________________________________ Physician’s signature

____________________________________ Physician’s Phone Number

____________________________________ Physician’s Fax Number

I agree that the North Hills School District and their assigned personnel shall not be held responsible for any untoward effects of this medication.

_____________________________________ Signature of Parent / Guardian

______________________________________ Daytime phone number

_____________________________________ Date

Please return the signed form to your child’s school nurse.