IBERVILLE PARISH SCHOOL BOARD

Parent/Legal Guardian's Consent for Medication

This form is to be completed by the parent/legal guardian and returned to the school nurse.

0. I hereby give permission for the school nurse or the designated unlicensed person, trained to administer medication at shool, to give the following medication, ___________________________, to my child, ______________________________ as prescribed by Dr. __________________________________. 
0. I give my permission to the school nurse to share with appropriate school personnel information (such as adverse side effects) relative to the prescribed medication administration as the nurse determines necessary for my son's/daughter's health and safety.   ____YES   ____NO
0. I understand that I may retrieve the medication from the school at any time and that the medication will be destroyed if it is not picked up within two weeks following termination of the order or two weeks beyond the end of the current school term.
0. I have administered the initial dose ordered at home and have allowed sufficient time for observation of adverse reactions before asking school personnel to administer the medication.   ____YES ____NO

NOTE:  ALL ANSWERS ABOVE MUST BE "YES" BEFORE THE MEDICATION MAY BE CONSIDERED FOR ADMINISTRATION AT SCHOOL BY UNLICENSED PERSONNEL, UNLESS OTHER ARRANGEMENTS HAVE BEEN AGREED ON BY PARENTS AND NURSE.

____________________________   _____________________

Signature of Parent/Legal Guardian Date

Relationship to Student ___________________________________