Parent request and physician's order for medication.xlsx

East Wake Academy
Parent Request and Physician's Order Form for Medication Student Name _________________________________________ Date of Birth ______________ Name of Medication
Route- How to Give
Time(s) to Give (Right
(Right Medication)
Dosage (Right Amount)
(Right Route)
Medication Log
Upon Exposure
 Upon Ingestion
Upon Exposure
15 minutes prior to
ergency Medication(s)
 __________________  Other ______________ 15 minutes prior to
(Same as Diazepam Ge  7.5 mg  10.0 mg After 10 minutes
 Other ______________ __________________ Physician Printed Name: ________________________ Physician Signature: _________________________ Date __________ Phone ____________ East Wake Academy
Parent Request and Physician's Order Form for Medication To be completed by Parent:
I understand that:
• Non-medical personnel conduct the medication administration. • It is my responsibility to have an adult transport the medication to school. • If medication is not available at the school 911 will be called for emergencies. • If my child participates in WCPSS before/after-school activities/sports, I will assume responsibility for contacting the advisor/coach of my child’s medical condition. I will provide extra emergency medications that may be needed during the activity. I may contact the school nurse if assistance is needed in instructing the advisor in a medical procedure or if a copy of the information needs to be I request that:
• My child be administered the medication as indicated in the physician’s order. • If an emergency injection is ordered, I give permission for the School Nurse to instruct designated staff in the administration technique I authorize:
• The release and exchange of medical information between my child's physician, school nurse, and East Wake Academy that is necessary in carrying out services for my child.
I hereby give my permission for my child to receive mediation during school hours. This medication has been prescribed by a licensed physician.
I hereby release the EWA Board of Directors and their agents and employees from any and all liability that may result from my child taking the prescribed medication.
Parent/Guardian Signature: ___________________________________________________________ Date:_____________________ Student Self-Carry and Self Administration of Emergency Medication
To be completed by Physician:
To be Completed by Parent:
The student must have the medication(s) listed on the reverse side during the school day or at school sponsored events in order to function at school. I request and give permission for my child to carry and give the medication listed on the reverse side Adult supervision is not needed. The
student has been instructed in the treatment plan, self-administration of the listed medication(s) during the school day, at school-sponsored activities or while in transit to or from school. and has demonstrated the skill level necessary to self-administer medications for: Adult supervision is not needed.
I understand that:

• I shall provide to the school back-up medication (in addition to what student will carry) that shall be  Other _______________________________________ • My child will be required to demonstrate the skill level necessary to use the self-administered For Epinephrine Auto Injector Only:
medications to school staff trained by the school nurse. any other manner than that prescribed In the event the student is experiencing respiratory difficulty and is unable to administer the Epinephrine • My child will be subject to disciplinary action if medication is used in any other manner than Auto Injector the School Nurse will train designated school staff to administer the Epinephrine Auto Injector Printed Physician's Name_________________________________________________ For Epinephrine Auto Injector Only:
In the event my child is experiencing respiratory difficulty and is unable to administer the Epinephrine
Physician's Signature _____________________________________________________ Auto Injector ordered by the physician, a trained school staff member may administer the Epinephrine To be completed by student at school:
I have observed my child demonstrate the necessary skill level to implement the care plan prescribed by  I have demonstrated the use of my medication to the school staff listed  I plan to keep medication and equipment with my at school Parent Signature _____________________________________________ Date _______________  I will use only as prescribed by my doctor  I will not allow any other person to use my medication To be completed by school nurse:
 I have observed the student indicated above verbalize and demonstrate the skill level necessary to use
 I will notify a school staff member if I am having more difficulty than usual with my health concerns the medication prescribed by the above physician.
Student Signature ____________________________________ Date ______________ Nurse Signature ____________________________________________ Date ________________


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