NORTH ALLEGHENY SCHOOL DISTRICT

Parental Medication Permission Form

Camp Kon-O-Kwee

Following school district policy, ALL medication sent to camp must be accompanied with either prescription label or written documentation from the Health Care Provider.   

All Medicine Must Be In Original Container Labeled With:

1.  Name of Child      2.  Amount of medication to be taken      3.  Time medication is to be taken

PRESCRIPTION MEDICATION

Student's Name                                                                           Home Room

Medication

#1

#2                                                  #3                                       #4

Dosage

 

 

Time

 

 

Amount Sent

 

 

Side Effects

 

 

Reason for

Medication

 

 

 

Physician/

Dentist

 

Name___________________

 

Phone _________________

 

Name _______________           Name ______________       Name _____________

 

Phone _______________           Phone______________       Phone _____________

For office use only   

                                                    Time medication administered and initials

Medication #1

 

 

Day 1

 

Day 2

Day 3

Medication  #2

 

 

 

 

 

 

Medication  #3

 

 

 

 

 

Medication  #4

 

 

 

 

 

 ___________________________________                        ________

nurse signature                                                                            initials

I give my permission for the Certified School Nurse to contact our physician or dentist, as necessary, regarding the medication I am sending with my child.

Parent Signature:

(C) _______________________________________ DATE:

TELEPHONE with Area Code - Home:   [_____________________________]

                                                        Work:   [_____________________________]

ONLY PRESCRIBED MEDICATION CAN LEGALLY BE ADMINISTERED

 BY LICENSED MEDICAL PERSONNEL.

 

 

 

 

 

 

 

R U L E S   F O R   T A K I N G   M E D I C I N E    AT Camp Kon-O-Kwee

 

The parent or guardian will assume full responsibility for any medication sent to camp.

 

  1. A parent/guardian must complete the “Parental Medicine Permission Form” listing each medication to be taken at camp.

 

  1. All prescription medication is to be in its original labeled pharmacy container.  Medication without prescription label must be accompanied by a health professional’s (M.D., D.O., Dentist, PA, CRNP) written request for administration which includes:

 

a.      Name of student

b.      Name of medication

c.       Name of qualified health professional

d.      Dosage

e.      Date

f.        Time of administration

 

  1. When delivering medication to school:

 

    1. Container is to be placed in a clear plastic bag with the completed form.
    2. Medication is to be delivered to the health office upon student’s arrival at school.  Please do not pack medication in the student’s belongings. 

 

  1. Medications that are routinely kept at school are not sent to camp unless specifically requested by the parent/guardian.

 

  1. When possible, send only the amount of meds necessary for camp.  All meds will be available for pick up upon return to school.   Students will not be given medication to take home unless accompanied by an adult at time of pick up.

STUDENTS ARE NOT PERMITTED TO CARRY PRESCRIPTION MEDICATION WHILE AT SCHOOL WITHOUT PRIOR PERMISSION.

 

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