Medication Forms

Medication Forms:

Click on the links below to access medication forms: print and complete forms and send with medication in its original labeled container. 

Permission for School Administration of Medication (for prescription or over-the-counter medication to be administered by school nurse)**

• • For prescription medications, the medication form(s) must be signed by a prescribing physician and ICD-10 code included.

  • Per LCSD Medication Guidelines, parents must provide any OTC medications to be given during the school day.  We do not stock OTC medications - oral or topical.

    • Over-the-counter medication must be in the original, unopened container with manufacturer's label. The parent/guardian should attach a label with the student's name to the medication and complete the Permission for School Administration of Medication form  

    • Medication to be given at school should be accompanied by this form, complete with the prescribing physician’s signature, if required, and provided to the school in the original labeled container. The medication, prescription or non-prescription, must be in the original labeled container. Non-prescription medication will be administered according to the manufacturer’s label. 

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Self-Medicating and/or Self-Monitoring Forms: (4+ FORMS TOTAL: All 3 forms must be completed and signed for self-administration of medications; additionally, each medication should have a seperate medication order [Permission for School Administration of Medication])

• LCSD Medication Guidelines require that a separate Permission for School Administration of Medication form be completed for each medication administered during the school day - prescription or over-the-counter.- This also applies to those students who have been given permission to self-medicate/self-monitor.

**Students who share any medication with another student will face disciplinary action including, but not limited to, suspension or expulsion.**

Student

Parent

Health Care Practitioner 

Declination Form: Please complete this form if your child does not require a health plan. (Ex. No longer needs and/or uses medication for asthma or allergy). It states: I have received information about the benefits of having the school nurse develop an individual health care plan (IHP) for my child. At this time I do not wish to have an IHP written for my child. 

Below are parent reminders from our LCSD Medication Guidelines:

>  A responsible adult must deliver the medicine to the school.  Do not send medication with the student.

>  Medication to be given at school must be accompanied by the Permission for School Administration of Medication form.

 > A separate Permission for School Administration of Medication form must be completed for each medication and/or each student.

 > The Permission for School Administration of Medication form must be renewed, at a minimum, at the beginning of each new school year.

>  If a student needs to carry an emergency medication (ex. Inhaler, Epi-pen, Insulin) or monitoring devices (ex. Diabetes) on his/her person, authorization forms completed and signed by the physician, parent and student are required. ALL 3 Self-Medicating and/or Self-Monitoring forms must be completed and signed.

>  Prescription medication must be in the original, labeled container provided by the pharmacist who filled the prescription.

>  Over-the-counter medication must be in the original, unopened container with the manufacturer's label and must not be past the expiration date printed on the container.

>  The parent/guardian should attach a label with the student's name to the medication.

Other Important Forms:

Diet Order Form for Students with Special Nutritional Needs