Byron-Bergen Central School Medication Administration Request

Dispensing medication in school is contrary to statutory regulations under the Nurse Practice Act and New York State Education Law. We realize, however, that it is sometimes necessary for a student to take internal medication during school hours. Certain requirements MUST be met for the administration of medication in school.

1. A written request from the physician indicating the frequency and dosage of the prescribed medication.
2. A written request from the parent to administer the medication
3. Medication must be in the original and properly labeled container. (Request a separate container for school use if necessary.)
4. Medication must be delivered to school by the parent/guardian. Should problems arise, parents should contact the school nurse for assistance.

To Be Completed by the Physician

_________________________________ is under my care and it is necessary that he/she be given the following medication during school hours.

Diagnosis: __________________________________________________________________

Medication: _________________________________________________________________

Dosage: __________________________________ Time: ____________________________

Possible Reactions: ___________________________________________________________

Date: _________________ Physician’s Signature: __________________________________

To Be Completed by the Parent/Guardian

I hereby request that my child, ______________________________ be given the medication as prescribed by his/her physician.

Date: _________________ Parent/Guardian Signature: _______________________________

MEDICATION REQUEST MUST BE RENEWED YEARLY FOR LONG TERM MEDICATION