Medication policy and permission forms

Click on the links to view and print forms:

Medication Permission Forms

• Prescription medication permission form 

• Over-the-counter medication permission form 

Emergency Care Plans (blank forms)

Note: Many providers have their own templates or forms included in their electronic health records systems, but if needed, you may print a template below to take to them for completion.

• Food Allergy & Anaphylaxis Emergency Care Plan from FARE

• Annual Asthma Action Plan from the VT Dept of Health

• Seizure Action Plan from the Epilepsy Foundation

• MRUUSD Parent Authorization Form for Self-Possession and Administration of Emergency Medication

Mill River Union School District BOARD POLICY

Title: Student Medication Policy No. 5140,   Warned: 6/15/09,   Adopted: 7/1/09

It is the policy of Mill River Union High School to have procedures in place to assure that medication required by students during the day will be administered and maintained in a safe manner as directed by the student’s parent, guardian or health care provider.

Implementation

1. The school nurse (or designee) will administer prescription medication upon receiving written orders from a physician. The physician’s order must identify the name of the drug, dosage, and the time to be administered, diagnosis, and reason for giving.

2. Prescription medication must be brought to school in a container labeled by the pharmacy or physician and stored in a secure, locked storage area in the nurses’ office.

3. Students with life threatening allergies or with asthma, whose parents or guardians comply with all of the requirements of Act 175 of 2008, shall be permitted to possess and self-administer emergency medication at school, on school grounds, at school-sponsored activities, on school-provided transportation, and during school-related programs.

4. Non-prescription medication must be brought to school in its original container and be accompanied by a written request for administration from the parent or guardian. This medication must be left in the custody of the school nurse or designee. Administration will be in accordance with the written request from the parent. The request must contain assurances that the student has suffered no previous ill effects from the use of medication. Medication must be left in the custody of the school nurse.

The school shall provide an opportunity for communication with the pupil, parent or guardian, and physician regarding the efficacy of the medication administered during school hours. In the case of medication possessed by students with life threatening allergies or with asthma, the school shall provide forms for parents to submit authorizing possession of the medication and releasing the school from liability as a result of any injury arising from the student’s self-administration of the emergency medication.

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Signature of Board Chair

Legal Reference: Vt. State Board of Education Manual of Rules and Practices 4220

Cross Reference: Mill River union Board Policy: Alcohol and Drug Abuse #5144

Standards of Practice School Health Services