MASSACHUSETTS SCHOOL HEALTH RECORD
MEDICATION FORM, PARENT-PHYSICIAN SIGNATURE(S)
Tantasqua Reg. Jr. High School, 320 Brookfield Road, Fiskdale, MA 01518
Voice 508-347-7381 Fax 508-347-3994
Medication in the original pharmacy container and accompanied by this Parent
Permission-Physician Order Form will be dispensed by authorized school personnel.
Short Term Medications that are given three or four times a day and
Prescription Pain Medications are to be handled at home. Transportation
of medicine to school will be arranged by the nurse and parent. Only
DOCUMENTED EMERGENCY MEDICATION (EPI PEN, INHALER, ENZYMES OR DIABETIC MED)
will be sent/given on field trips.
Student __________________________________ DOB ______________ Grade
_______
Mail Address __________________________________Town/Zip ___________________
Home Phone ______________Work Phone _____________Emer. Phone ______________
Emergency Contact ______________________________________ Phone
_____________
Other medication(s) taken at this time*
_________________________________________
Allergies
__________________________________________________________________
I give my child permission to SELF CARRY and ADMINISTER and EPI PEN, an INHALER
or DIGESTIVE ENZYMES at school and on field trips. Yes_____ No ______
And I give the school nurse's designee permission to supervise/assist with
the documented emergency medication on the field trip as needed.
** ON DAYS OF DELAYED SCHOOL OPENING, HOME MEDICATION SHOULD BE GIVEN AT THE USUAL TIME TO AVOID LUNCHTIME MEDICATION CONFUSION.
** DAILY MEDICATION WILL NOT BE GIVEN ON EARLY RELEASE DAYS OR FIELD TRIPS UNLESS SPECIFICALLY REQUESTED IN WRITING BY THE PARENT.
** DOCUMENTED EMERGENCY MEDICATION (IF NOT SELF-CARRIED) WILL BE SENT ON A FIELD TRIP PROVIDED YOU CONTACT ME PRIOR TO THE TRIP SO THAT I MAY MAKE THE NECESSARY ARRANGEMENTS WITH THE STAFF IN ADVANCE.
I agree that the nurse may share this medication information if relevant
to the welfare of my son/daughter, and I understand that I may retrieve the
medication at any time. NOTE that medication not retrieved will be
destroyed at the end of the school year.
__________________________ ___________________________ ________
Parent (Print name)
Parent/Guardian Signature
Date
*********************** MEDICATION FORM FOR PHYSICIAN
***********************
DIAGNOSIS* __________________ MEDICATION
_______________________________
DOSE _________________ ROUTE__________ TIME ________ DURATION _________
MAY SELF-ADMINISTER. YES _____ NO ______
WARNINGS _______________________________________________________________
OTHER MEDICATIONS BEING TAKEN BY STUDENT __________________________
OFFICE PHONE ___________________ EMERGENCY PHONE ____________________
______________________________________________________ ____________________
SIGNATURE OF LICENSED PRESCRIBER
DATE
* If not in violation of confidentiality (4/03/bb)