NEVADA JOINT UNION HIGH SCHOOL DISTRICT

MEDICATION REQUIRED DURING SCHOOL HOURS

California Education Code #49423 allows the school nurse or other designated school personnel to assist students who are required to take medication during the school day. This service is provided to enable the student to remain in school to maintain or improve the potential for education and learning.

Medication must be in the container in which it was purchased. If it is a prescription medication, the container label must indicate the student’s name to whom it will be administered. No medications (including over-the-counter medications) will be given at school without a current prescription from a California licensed physician.

Student Name: ___________________________________________________ Grade __________________

School _____________________________________ Birthdate_________________________________

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TO BE COMPLETED BY HEALTH CARE PROVIDER:

Date Student examined: _____________________________________

Diagnosis: _______________________________________________________________________________

Medication: 1 _____________________________________ Times _________________________________

2 _____________________________________ Times _________________________________

3 _____________________________________ Times _________________________________

It is necessary for this medication to be taken during the school day at the time(s) indicated above. The medication may be administered by medically untrained personnel.

For field trips only – with school permission student may carry and self-administer above medications

Yes	No	Physician’s Initials _______________________

Physician Signature: ______________________________________________________________________

Physician Name (please stamp or print): ____________________________________ Date: ________________

Address: __________________________________________________ Phone: ________________________

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TO BE COMPLETED BY PARENT/GUARDIAN

I authorize school personnel to administer the above medication to my student as ordered by the physician listed above. I understand that this medication may be administered by medically untrained school personnel. I give my consent for the school nurse to communicate with the physician/health care provider and to counsel with school personnel regarding the above named student.

Parent/ Guardian Signature: ___________________________________ Date: _______________________

This form must be renewed whenever the prescription changes and at the beginning of each school year.

All medication not picked up by parent or guardian at the end of the school year will be discarded.

All medications that are kept in the Nurse’s Office are available 7 AM – 2:30 PM only.

Park Avenue Alternative Education Site 140 Park Avenue, Grass Valley, CA 95945 Phone 272-2635 Ext. 300

Fax 272-8564.	Revised 9-3-08