WAYNE COUNTY SCHOOLS

REQUEST FOR MEDICATION AT SCHOOL

(Prescription and Non-prescription)

Student’s Name ______ School___________________

Birth date __ Grade_____ Parent’s name ______________________________
TO BE COMPLETED BY PHYSICIAN:
Prescription date __________Date of order_________ Discontinuation date _____________
Name of medication _____________________________ Dosage______________
Route of administration_____________ Frequency of administration__________________
Diagnosis_______________________________________________
Intended effect of medication____________________________________
Other medication student is receiving___________________
Time interval for reevaluation_____________________
Possible adverse effects of this medication______________________________________________
Is it necessary for this medication to be administered during the school day? ____Yes ____No
Lay person may be trained to administer this medication_______________
Physician printed name ________________________ Signature ____________________________
Telephone # ________________ Address________________________________

TO PARENT/GUARDIAN:
Medication must be brought to school in a container appropriately labeled by the pharmacy
or physician; nonprescription medications ordered by a physician should be brought with the
original label and the student’s name affixed to the container. Only those medications which are
necessary to maintain the student in school or must be given during school hours shall be
administered. If you have any questions, please call the school nurse.
The school district and its employees and agents are to incur no liability, except for willful
and wanton misconduct, as a result of any injury arising from the self-administration of medication
by the pupil.
I hereby authorize the above named school and its employees to act in my behalf to
supervise the administration to by student (or supervise self-administration) the medication
prescribed above. I acknowledge that a school nurse may not be available to supervise the
administration and specifically consent to school employees giving the medication instead of the
school nurse.

Date____________ _______________________________________
(Signature of parent/guardian)
Phone________________ Emergency/work phone # ___________________

TO PARENT/GUARDIAN OF STUDENTS WHO NEED TO CARRY ASTHMA MEDICATION

OR EPINEPHRINE AUTO-INJECTOR:
I authorize the School District and its employees, to allow my student to carry and self-
administer his/her asthma inhaler and/or epinephrine auto-injector while at school, school sponsored
activities, under the supervision of school personnel, or before or after normal school activities.
Illinois law required the School District to inform parents/guardians that it, and its employees, incur
no liability, except for willful and wanton conduct, as a result of any injury arising from a student’s
self-administration of medication (105 ILCS 5/22-30).

Please initial to indicate awareness of this information and authorization for your student to carry
and use his/her inhaler or epinephrine auto-injector. _______________________________