District 110 – waconia public schools

Parent Request for Medication Administration and Physician Order
Parents of pupils requesting that medication be administered during school hours must provide for the school: • Medication in an appropriately labeled container, over the counter medications must be in original container and prescription medications in a prescription bottle. • A physician signature on form for both prescription and non-prescription. Ask for prescription medications to be divided into two bottles completely labeled – one for home and one for school. Only when a medication is prescribed to be taken during school hours will a student be given medication at school. Student Name:____________________________ Birth date:_____________ School:_____________ Gr:_______
Medication:_________________________________________ Route: Oral _____ Inhaled_____ Topical_____
Dosage:______________________________________________________ Time Given:_______________________
Treatment Of:____________________________________________ Number of tablets sent to school:__________
Possible Side Effects:_____________________________________________________________________________
Special Instructions:______________________________________ End Date/Number of days given:__________
Allergies:_______________________________________________________________________________________
I request that this medication be given as indicated above. I understand that administration of medication will not necessarily be done by a School Nurse or Health Associate, but may be provided by a designated trained school employee. Also, if necessary, the school may request additional information from the physician regarding this illness or medication. Sign form below and return it with the medication to the school health office.
PARENT/GUARDIAN SIGNATURE:______________________________________________________________
Date:______________________ Daytime Phone:______________________________________________________
PHYSICIAN SIGNATURE:_______________________________________________________________________
Print Physician Name:__________________________________________ Phone/Fax:_______________________
Below line for School Health Office Use only:
Date/Time
Date/Time
Date/Time
Date/Time
Administrator Signature
Dose/Initials
Dose/Initials
Dose/Initials
Dose/Initials
Cologne Academy Medication Policy
Cologne Academy acknowledges that some students may require prescribed oral medications during the school day to function as near to their potential as possible. Cologne Academy’s school nurse, health associate, or other designated trained school employee will administer prescribed medications under these conditions: • Prescription and non-prescription medication requires a completed signed authorization form from the
student’s parent/guardian and physician. Cologne Academy may rely on an oral request to administer medication
for up to two days until written authorization is received. It is to include:
This authorization can be faxed to 952 466-4030 • Prescription or non-prescription medication must be in the prescription or Over-The-Counter labeled
container. The pharmacy will divide medication for home and school into two bottles with proper labels.

• Parent/Guardian will notify the Health Office of any changes in medication or if it is discontinued. A written
script from the physician will be needed for any changes. This can also be faxed 952 466-4030. • The school WILL NOT provide any medications including Aspirin, Tylenol, Ibuprofen, cough drops,
Bacitracin (Neosporin), etc., in accordance with Minnesota Department of Health guidelines.
• Students will not be allowed to self-administer or carry medications with them unless an exception is made,
and a written plan is agreed upon between the school nurse or health associate and parent.
• Cologne Academy will not administer any “dietary supplements”, herb products, or any other products not
regulated by the Food and Drug Administration. The quality and quantity of their products are free from the
scrutiny of a regulatory agency. The labels also do not indicate the action, recommended dosage for age, side effects,
interactions, adverse reactions and contraindications.
• Due to the number of students requiring medication to be given at school and out of concern for the safety and well- being of all of our students. Cologne Academy will follow these guidelines regarding the following medications: o Central Nervous System Stimulants (Ritalin, Adderall, Dexedrine, Cylert, etc.)
o Antipsychotics (Thorazine, Mellaril, Stelanzine, etc.)
o Antidepressants (Lithium, Paxil, Serzone, Prozac, Zoloft, etc.)
The parent/guardian is to choose ONE of the following options:
1. An adult will hand carry the medication to the school health office.
2. An adult will call the student’s school health office to alert the School Nurse or Health Associate of the
number of tablets that were sent to school with student. Health Services will count the number of tablets received, store them in a locked cabinet, and administer the correct dosage to the student at the time noted on the, “Medication Administration and Physician Order”, sheet.

Source: http://cologneacademy.org/wp-content/uploads/2011/09/med-administration-form-and-policy.pdf