MEDICATION ORDERFor use during scho

MEDICATION ORDER
For use during school hours and school trips.
2015-2016
Parental Consent to Administer Drugs /
Release of Liability
Medication Policy
• All medication must be kept in the school clinic.
• No medication will be dispensed without an initialed and signed
Medication Order form.
• Prescribed medication must be by a physician licensed to
practice medicine in the State of Texas.
• All medication must be appropriately labeled in the original
container by the pharmacy or physician, no zip lock baggies.
• Inhalers must be kept in the school clinic unless parent and
nurse approval is on file (6th – 12th grade).
• Stamped signatures cannot be accepted.
• OTC (over the counter) medications are only for 1st-12th grade
students.
I/We, the undersigned parent/s of my child, hereby instruct and expressly authorize The Village School, its
employees, agents, representatives and contractors to administer the described drugs (opposite of this page) to such
child according to the dosage designated.
Each of the undersigned also expressly RELEASES, INDEMNIFIES, and HOLDS The VILLAGE SCHOOL, its
employees, agents, and representatives HARMLESS of and from all liability, claims, demands, expenses, attorney fees,
and other costs incurred which arise or are incurred in connection with the administration of the drugs described. This
authorization may not be revoked or amended without written notice of such change actually delivered to an officer of
The Village School. All notices hereunder shall be in writing and may be effected by personal delivery in writing or by
certified mail, return receipt requested, addressed to The Village School at 13077 Westella, Houston, Texas, 77077 and
to the parents of the subject child at the address set forth below their respective signature.
Each of the undersigned parents represent to The Village School that they are authorized to make and execute
this Authorization and Release of Liability and that the authorization of another person is required to completely
authorize The Village School, its agents, employees, and representatives to administer such drugs to the above-named
child. The undersigned parents also understand that the Village School is relying on this document in undertaking to
administer the drugs to their child.
I/We also give permission for the information on this health form to be shared with school personnel on a need to
know basis in order to provide appropriate services to my child. I agree to notify the school of any changes in my child’s
health status. In the event of an emergency, I give permission for treatment of my child by school personnel or a
physician. The school will notify the parents as soon as possible.
Signature of Parent/Guardian:_______________________________________Date:_____________
(no pencil please)
STUDENT NAME:
GRADE:
ALLERGIES:
Epipen/AuriQ at School Yes No
Inhaler at School Yes No
Parent must INITIAL inside the box.
Check marks are not accepted.
The following school stocked medication is given as directed for a child’s age:
Acetaminophen (Tylenol)
Ibuprofen (Advil, Motrin) for fever/pain
Benadryl Liquid (for severe allergic reaction)
Tums for upset stomach (12 yrs. & older)
PRESCRIPTION MEDICATIONS/OTC REQUEST BY PARENT
Medication Name: Dose:
Route: Start Date:
Frequency: Discontinue Date:
Diagnosis:
Parent Name: Date:
Physician’s Name & Signature: Date:

13077 Westella, Houston, Texas 77077 281-496-7900 281-496-7799 fax

