St.Cecilia Catholic School
SCHOOL POLICY REGARDING THE DISPENSING OF MEDICATION AT
SCHOOL(PRESCRIBED OR OVER-THE-COUNTER
DRUGS SUCH AS TYLENOL)
In order for school personnel to administer prescribed or over-the
counter drugs such as Tylenol to a student, the following information must be on file (this
form is to be completed in full and turned in to the school office)
No Medication will be given by school personnel without the written consent
of a physician and parent.
Name of Pupil:_____________________ Date of Birth _________________Address:_________________________________Zip
Code: ____________
Phone: _____________School: ______________________________________________________
Grade: ____________________
TO BE COMPLETED BY THE CHILD'S PHYSICIAN:Name of Medication: ________________________________________________________________
Dosage: ________________________________________________________________
Duration of Dosage: ________________________________________________________________
How Administered: ________________________________________________________________
Date to Begin Administering Medication: ________________________________________________________________
Date to Terminate Administering Medication: ________________________________________________________________
Possible Side Effects: ________________________________________________________________
Physician's Name (print or type): ________________________________________________________________
Physician's Phone: ________________________
Physician's Emergency Phone:
_______________
Special Instructions
for Re-administering/Storing of Medication: _____________________________________
Physician's Signature: ________________________________________________________________
NOTE: The medicine must be in pill, capsule, or
spoon form. It must be in a clearly marked container from the pharmacist. The label must show the child's name,
the dosage directions, the doctor's name and the prescription number.
TO
BE COMPLETED BY THE PARENT: The undersigned agree not to file or make any claim against anyone for the negligence in connection with the
administration or non-administration of any medicines and further agree to save such individuals and hold them harmless
from any liability incurred as a result of the administration or non-administration of any medicines. I give my permission
for the Principal or his/her designee to administer the prescribed medication.
_________________________________________________________ Date: ___________________________
Signature of Parent/Parent Surrogate
THIS PERMISSION IS NO LONGER VALID AT THE END OF THE CURRENT YEAR.