Immaculate Heart of Mary School Medication Procedure

1. Each medication requires a separate form to be filled out and returned.
2. The medication must be in the current, original container with your child's name on the prescription. All medications are to be dispensed by the office. All temperatures will be taken by the office.
3. No medication to be given over three times daily will be administered at school.
4. The consent form must be signed before any medication will be given.
5. This includes ALL medications, whether prescription or over-the counter. (This includes cough drops, throat lozenges, etc.)
6. These guidelines are for your child's safety and in compliance with state law.

HANDWRITTEN NOTES ARE NOT ACCEPTABLE.

Date: ______________

Student’s Name/Grade___________________________________

Immaculate Heart of Mary School has my permission to administer the following drug or medication. I will not hold the School Staff responsible for any undesired reaction which may occur from the mediation. I agree to pay for ambulance service if used to transport my child from school to the doctor or hospital should he/she have a reaction the medication.

Drug/Medication name______________________ Dosage to be given: ______________

Time to be given: ____________________ Date(s) to be given: ____________________

Special Instructions: _______________________________________________________

In case of an emergency, call___________________________ Phone________________

Hospital to be called_________________________________ Phone________________

Doctor to be called__________________________________ Phone________________

Parent’s Signature: ________________________________________________________

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*****For Office Use*****
Record time and date medication was given and initial.