SALISBURY CENTRAL SCHOOL
AUTHORIZATION FOR THE ADMINISTRATION OF MEDICINES BY SCHOOL PERSONNEL

Connecticut State Law and Regulations require a physician or dentist's written order and parent/guardian's authorization for a nurse to administer medications or in her absence, the principal or teacher to administer medications. Medications must be in pharmacy prepared containers and labeled with name of child, name of drug, strength, dosage, frequency, physician or dentist's name and date of original prescription.

Name of Child:_____________________________________________ Date of Birth____________

Address________________________________________________________________________

Physician's Name:________________________________________________________________

Physician's Order:

Name of Drug:__________________________Dosage:__________________________________

Time of administration_____________________________________________________________

Condition for which drug is being administered __________________________________________

Relevant side effects _____________________________________________________________

Length of time which medication shall be administered:

From:__________________________ to _____________________________________________

Physician's/Dentist's Signature___________________________________ Date_______________

Nurse/Principal/Teacher_________________________________________ Date______________

Parent's Permission:

I give permission for the above medication to be administered to my child as prescribed above, by the appropriate school personnel.

Parent's Signature____________________________________________ Date_______________

Please return to Salisbury Central School at fax number (860) 435-2689.

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Updated March 19, 2007