5medication 13-14 permit-2

All medications require written authorization. See policy on reverse. This form must be renewed annual y. One form per student. Student’s Name:__________________________________Birthdate:______________Grade:__________Date:_____ Address:_________________________________________Telephone:____________________________________ Medication al ergies:____________________________________________________________________________ Asthma Inhaler, Epi-pen/Benadryl or Insulin and Glucose monitoring may “SELF CARRY” and “self-administer”

Asthma Inhaler medication: __________________________________________________ A student may carry their own “pharmacy labeled” Asthma
with the “parent” authorization only & self medicate as instructed by parent/physician.
: __________________________________________________________ A student may carry an Epi-pen (epinephrine injection)
and or Benadryl
with a “physician and parent” authorization.

Insulin and glucose monitoring supplies
: _______________________________________ A student may carry Insulin and glucose monitoring
with a “physician and parent” authorization.
*My child is capable of using this medication “independently” and “may carry” the above listed medication.
Parent signature acknowledges parent understanding of item #4 self-administration on the reverse of this form
Parent signature:_______________________________________________________________________Date:___________

Al medications must be brought to the Health Office by the parent/guardian in a prescription-labeled container or in the original over the counter medication container.

Parent/Guardian signature acknowledges authorization of Winnetka School District 36 to administer medication to my child according to school board policy
and medication administration procedures and guidelines on the reverse side of this form.

*Parent/Guardian Signature: _____________________________________________________________Date: ___________

Diagnosis: _____________________________________________________________________________________________
Medication:_________________________________________________Strength:____________________________________ Dose:______________________________________________________Route:_____________________________________ Time to be given at school:_____________________________________Start date:__________________________________ Intended Effect: _____________________________________________Possible adverse reaction: ______________________ Other medications this student is taking: ________________________________ Physician’s Name (Please Print)______________________________________ Phone________________________________Fax________________________ Address_____________________________________________________________________________________________
*Prescriber’s Signature
: ___________________________________________________
Date: __________________

Winnetka School District 36

Administration of Medication to Students
Parents/guardians have primary responsibility for the administration of medication to their children. The administration of medication to students during regular school hours and during school related activities is discouraged unless necessary for the critical health and wel being of the student, to maintain the student in school, or in the event of an emergency. The administration of medication to students is subject to guidelines established by the Superintendent or designee, in keeping with state agency recommendations (e.g., Il inois Department of Professional Regulation, Illinois Department of Public Health, and Il inois State Board of Education). Procedures and Guidelines
1. Medication Authorization Form—No school personnel shal administer to any student, nor shal any student possess or consume any prescription or
non-prescription medication except after “filing a complete medication authorization form”. This authorization and any subsequent changes shal include:
*Licensed prescriber’s written, signed and dated prescription. Licensed prescribers include physicians, advanced practice registered nurses, physician’s assistants, dentists and podiatrists. The prescription shall include the child’s name, date of birth, medication name, date of order and date of discontinuation, if applicable. *The child’s diagnosis related to the medication, possible adverse effects, and other medications being taken. *Administration instructions including: dose, route, and frequency. Please note: Medications taken three times a day should be given at home before school, after school, and at bedtime; unless specifical y ordered otherwise. The school nurse wil review the written authorization and wil consult with the parent/guardian, licensed prescriber, or pharmacist for additional information if necessary. Nurses are responsible for their own actions regardless of the licensed prescriber’s written order, and have the right and
responsibility to decline to administer a medication if they feel it jeopardizes student safety. In such instances, the nurse must notify the parent/guardian,
the student’s prescriber and the school administration.
2. Appropriate Containers—Medication and refil s are to be provided in containers which are:
*Prescription-labeled by a pharmacy or licensed prescriber (must display student’s name, prescription number, medication, dose, directions for administration, date and refil schedule, pharmacy label, and pharmacist identifying information). Please ask the pharmacist for a second, properly labeled bottle for school. *Manufacturer-labeled container for non-prescription over the counter medication. Medications sent to school in lunch boxes, baggies, envelopes or like containers wil not be dispensed.
3. Administration—Medication wil be administered by a certificated school nurse, registered nurse, or school administrator. Teachers or other
employees cannot be required to administer medication or supervise self-medication, although they may volunteer to do so after receiving training in the
correct procedure. This does not prohibit any school employee from administering emergency assistance to a student. If no volunteer is available, the
parent/guardian must make arrangements for administration. A student’s parent/guardian may come to school to administer medication to his/her own
child. The school nurse or administration retains the discretion to deny requests for administration of medication. A one-time dose can be given with
parent/guardian permission. No further doses wil be provided without the completed medication permit on file.
4. Self Administration—A student may self-administer medication at school and activities if so ordered by his/her medical provider. A completed
medication authorization form must be on file. Daily documentation will be provided as below (#5) for such health office supervised self-administration. For “as needed” medications such as those taken by students with asthma and al ergies, the prescriber may also order that the student carry the medication on his or her person for his/her own discretionary use according to medical instructions. However, no daily documentation wil be possible. Self administration privileges may be withdrawn if the student exhibits behavior which indicates lack of responsibility toward self or others in regard to his or her medication. Signature of the parent on this form indicates that parent/guardian acknowledges that the school district is to incur no liability, except for wil ful and wanton conduct, as a result of any injury arising from the self-administration of medication by the pupil and that the parents/guardians indemnify and hold harmless the school district and its employees and agents against any claims, except a claim based on willful and wanton conduct, arising out of the self-administration of medication by the pupil. This student has been instructed in the proper administration of this medication and understands the need for the medication and the necessity to report unusual side effects or symptoms to school personnel. A student may carry his or her own “pharmacy labeled” asthma inhaler with the parent authorization only instead of a written doctor’s order. 5. Storage and Record Keeping—Medication wil be stored in a locked cabinet. Medications requiring refrigeration wil be in a secure area. Each dose
wil be recorded in the student’s individual health record. In the event a dose is not administered, the reason shal be entered in the record. The parent
may be notified if indicated.
6. Documentation, Changes, Renewals and Other Responsibilities—To facilitate needed documentation, medication prescriptions or dosage
changes and parent permission forms may be faxed. It is the parent/guardian’s responsibility to assure that al medication prescriptions and required
forms are brought to school, refil s provided when needed and to inform the school nurse of any changes in the student’s health or medications.
Medication remaining at the end of the school year wil be discarded unless removed by the parent/guardian. Medication authorization forms must be renewed every year both for prescription medication and for over the counter medications. Copies of this policy and form shall be given to the parents/guardians of each student every school year.
Crow Island School Health office 847-446-1048 fax 847-446-9021
Greeley School

Health office 847-446-2638 fax 847-501-5737
Hubbard Woods
Health office 847-446-1062
fax 847-501-6124
Skokie School
Health office 847-441-2194 fax 847-441-2193
Washburne School Health office 847-446-6260 fax 847-446-1380

Source: http://web.winnetka36.org/registration/health/D36MedicationPermit.pdf

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