School District of Fort Atkinson - Administering Medication to Students

Student Name___________________________________        Physician's Name____________________________

Birth date_______________  Male______  Female______        Physician's Address__________________________

School____________________  Grade_______________       __________________________________________

Teacher (if applicable)_____________________________       Physician's Phone____________________________

Parent/Guardian_________________________________        Physician's Fax______________________________

Home Phone______________  Work Phone______________ 

To Parent/Guardian/Physician:

The School District of Fort Atkinson is required by state statue to give prescription medication to students only
with the complete directions from a physician and signed consent by parent/guardian.  Medication must be supplied
in the original container or packaging.  For safety and liability reasons, medication received in any container other
than the original will  not be acceptable for staff administration.  By signing this form, you release the Board of
Education, it's agents and employees from any and all liability which may result from taking this medication.

Medication_______________________________________  Dosage_______________  Frequency__________________

                                Start Date_____________________  End Date_____________________

Form:  _______Tablet/Capsule  _______Liquid  _______Inhaler  _______Nebulizer  _______Injection

            _______For Epsodic/emergency events only  _______Other____________________________________________

*Emergency Medications (inhaler, glucagon, insulin, epi-pen).    Student to self-administer/carry:  Yes_______  No________

Time(s) to be given_____________________  Reason for this medication_______________________________________

If given on an "as needed" basis, please describe___________________________________________________________

Special Instructions:_________________________________________________________________________________

Side Effects (expected or predictable)____________________________________________________________________

Physician's Signature___________________________________________________  Date_______________________
(Signature required for all prescription medication and for non-prescription medication that exceeds the manufacturer's
 recommended dosage.)

Parent/Guardian Signature_______________________________________________  Date_______________________
(Signature required for all prescription and non-prescription medication.)



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