COE-BROWN NORTHWOOD ACADEMY
907 FIRST NEW HAMPSHIRE TURNPIKE
NORTHWOOD, NEW HAMPSHIRE 03261
Telephone: (603) 942-5531
FAX: (603) 942-7537

David S. Smith, Headmaster
Paul W. Davis, Jr. Asst. Headmaster
Sally A. Aseltine, Dean Student Services
Stephen H. Smith, Guidance
Anne H. Onion, Guidance

ADMINISTRATION OF MEDICATION IN SCHOOL

Any student who is required to take during the school day, a medication prescribed by a licensed physician, ARNP, or a PA shall be supervised by the school nurse or designee.

a. A written statement from the prescribing licensed prescriber, detailing the medication, dose scheduled time of administration and the side effects to be observed and length of time for the course of treatment.
b. A written authorization (request) from the parent/legal guardian of the student indicating the desire that the school assist the pupil as set forth in physician's statement.

Physician's statement

I hereby instruct the designated member of the school staff to assist:
___________________________ in taking the following medication(s):
(Student name)

Medication

Dose

Route

Time (Schedule)

Duration

Side Effects
1)          
2)          
3)          



 

 


Student may carry medication (#____) on person _____Yes _____No

** For asthmatics or those using an inhaler: Baseline Peak Flows: Green____ Yellow____ Red____

_______________________________________
__________________
(Physician Signature)
(Date)
__________________________________
____________________
____________________
(Printed Physician Signature)
(Phone Number)
(Fax Number)

PARENT/LEGAL GUARDIAN AUTHORIZATION

I hereby request and give my permission for the school nurse and/or designee to assist my child, _________________________ in taking the following medication(s) (listed above) prescribed by my physician. I release said person from responsibility for any adverse effects from the medication(s) or from the effects when my child refuses to cooperate in taking said medication(s). I also authorize that if necessary, the school nurse and the above physician may share information relative to the health of my child.

_______________________________________
__________________
(Parent/Legal Guardian signature)
(Date)

Other medications child is currently taking: ________________________________________ Please send only enough for one month at a time. Medication must be delivered directly to the school nurse or designee by the Parent/Legal Guardian or responsible adult in the original prescription container from the pharmacy or manufacturer's container.