AUTHORIZATION FOR ADMINISTRATION OF MEDICINE

The Awty International School
Houston
AUTHORIZATION FOR ADMINISTRATION OF MEDICINE LES FORMULAIRES D’AUTORISATION POUR REGLEMENT SUR LES MEDICAMENTS
This authorization is for permission to administer prescription, scheduled and or over the counter
medications to my child. The medication is listed below and is to be given at a scheduled time. This
permission will be effective from August 1, 2013 through August 30, 2014
Student’s Name ______________________________________________________________________
First
Middle initial
Last
Date of Birth
___________________________
Grade Level______________________
It is necessary for the following medication to be administered regularly during school hours in the form and dosage
specified below in order to maintain this child’s physical health and optimal school performance.
Name of medication ________________________________________________________
This medication is to be given for the following reason: (e.g. Headache, Strep Throat, Stomach ache)
______________________________________________________________
How long is this medication to be given? (e.g. one week, two days, as needed) _______________________
Dosage (e.g. one teaspoon, one tablet) ____________________________
Side effects _______________________________________________
Time medication is to be administered: ____________________________
Please indicate how medication is to be given: [ ] By mouth [ ] Inhalant [ ] Nasal spray
[ ] Injection [ ] Topical (e.g. ointment) [ ] Other ____________________________
I hereby grant permission for the School Nurse and or a delegated representative at the school to administer the medication
named above to my child. The “over the counter” medication and or the prescription medication will be in its original container.
The over the counter medication will be labeled with my child’s name, grade, section and time of administration. The prescribed
medication will be labeled by a U.S. pharmacy with the child’s name, name of medication, and clear directions for
administration.
Release of Information: In the interest of having a collaborative effort on behalf of my child’s well-being at school, I give
permission for the school nurse to exchange health information with the health care provider listed below and teacher(s)/staff as
indicated about the medication (s) he/she is receiving.
______________
Date
_______________________________________________________________
Parent/Guardian signature
Home Phone Number: _____________________ Cell phone number: __________________________
Work Phone Number: _____________________ Pager number: _________________________________
*Physician signature: _______________________Phone Number: (____)________________Date_______
*Physician’s signature needed if medication is administered more then 15 consecutive days.
The Awty International School
Houston
2013-2014
Guidelines for Administration of Medications at School
Parents,
Your child may have a condition that requires medication for relief or cure that does not prevent his/her attending
school. When possible, such medication should be scheduled to be taken at home. However, according to the Texas
State Legislature and Awty School Policy, school personnel may give a medication to a student. The parent or legal
guardian requesting this service must meet the following requirements:
1. USA prescription or USA non-prescription “as-needed” drugs that need to be taken at school for 15 days or
less:
a. All prescription drugs must be in their original pharmacy container and labeled by the pharmacist.
The label must include:
1. Student’s Name
2. Physician’s Name
3. Name of Drug
4. Amount of drug to be given and frequency of administration
5. Date prescription filled
b. All non-prescription drugs must be in their original container. The written request for administration
of these must contain the following information:
1. Student’s Name
2. Name of Drug
3. Amount of drug to be given
4. When drug is to be given
5. Reason drug is given
6. Date
7. Signature of parent/guardian
c. All prescription and non-prescription drugs to be administered at school for 15 days or less must be
accompanied by a written request, signed and dated by a parent or legal guardian. (Form on
reverse side)
2. USA prescription or USA non-prescription drugs that need to be taken at school for more than 15
consecutive days:
All prescription and non-prescription drugs to be administered at school for longer than 15 days must be
accompanied by a written request signed and dated by the prescribing physician and the parent or
guardian requesting this service. (Form on reverse side)
3. Medications prescribed or requested to be given three times a day or less are not to be given at school unless a specific
time during school hours is prescribed by a physician, or the school nurse determines that a special need exists for an
individual student.
4. There will be no more than one medication per properly labeled container.
5. All medications will be stored and given in the school clinic. School nurse must approve exceptions in
advance.
6. No students may have prescription or non-prescription drugs in his/her possession on school
grounds during school hours. MS//US students may carry asthma inhalers if approved by their
doctor/parent and an asthma action plan is on file in the clinic.
7. No long-term medication will be administered from or kept in the school health center for more than 15 days
unless otherwise prescribed by a physician or dentist.
8. In accordance with the Nurse Practice Act, Texas Code, Section 217.11, no homeopathic medications are
allowed. The school nurse has the responsibility and authority to refuse to administer medications that in
the nurse’s judgment are not in the best interest of the student.
9. Frequent use of as-needed medications such as Tylenol, Advil, etc. may require Doctor’s
Signature as requested by the school nurse.
Please contact the clinic if you have any questions about your child’s medication needs at school.
Sincerely,
Gina Sharman RN
School Nurse
Veronique Moore RN (French speaking) School Nurse
The Awty International School
Houston
Procédures pour l´administration de médicament à l´école Awty
2013-2014
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Chers Parents/Gardiens,
Dans le cas où votre enfant doit prendre des médicaments dans le cadre d´un traitement, l´administration de ces
médicaments devrait avoir lieu au domicile si possible. Toutefois, en accordance avec la loi du Texas et le règlement
d´Awty, le personnel de l´école peut administrer ces médicaments aux élèves. Seuls les médicaments américains
peuvent être dispensés. Dans ce cas, les parents ou gardiens légaux doivent fournir les documents suivants :
1- L´administration de médicaments avec ou sans ordonnance et pour une durée de moins de15 jours doit
être accompagnés d´une demande écrite et signée des parents :
a. Les médicaments délivrés sous ordonnance doivent être dans leur boîte d´origine. L’étiquette doit
mentionner :
- le nom de l´élève
- le nom du médecin
- nom de médicament
- la quantité et fréquence d´administration du médicament
- la date de l´ordonnance
b. Les médicaments sans ordonnance doivent être dans leur boite
d´origine et accompagnée d´une demande écrite comportant :
- le nom de l´élève
- le nom du médicament
- la quantité et fréquence d´administration du médicament
- raison pour administrer le médicament
- date et signature des parents/gardiens
2-
La demande d´administration de médicament pour une durée de plus de 15 jours doit être accompagnée
d´une demande écrite des parents ou gardiens légaux ET du médecin prescrivant le médicament.
3- Les médicaments prescrits et devant être pris trois fois par jour ou moins devront l´être en dehors des
heures scolaires si possible.
4- Pas plus d´un médicament par boite.
5- Les élèves ne doivent pas garder de médicaments sur eux. Ils doivent rester et être dispensés à
l´infirmerie. Les élèves du collège et lycée peuvent garder leur traitement pour l´asthme avec eux
si un plan de traitement et une note des parents/médecin est disponible à l´infirmerie.
6- Les traitements de long cours (plus de 15 jours) doivent impérativement être accompagnés par un mot du
médecin ou dentiste.
7- En accordance avec le Nurse Practice Acte., code du Texas, Section 217.11, les médicaments
homéopathiques ne sont pas autorisés. De plus, l´infirmier(e) peut refuser d´administrer un médicament
considérer non essentiel pour l´élève.
N´hésitez pas à nous contacter si vous souhaitez de plus amples renseignements ou pour toutes questions.
Gina Sharman, RN, School Nurse
Veronique Moore RN (French speaking) School Nurse