SCHOOL___ALTA LOMAHIGH ___________________
PHONE_
AUTHORIZATION FORADMINISTRATION OF PRESCRIBED AND OVER THE COUNTER MEDICATION AT SCHOOL
STUDENT NAME____________________________________BIRTHDATE____/____/____
Education code 49423 authorizes that any pupil who isrequired to take medication prescribed for him/her by a physician during theschool day, may be assisted by the school nurse or other designated personnel ifthe school district receives: (1) a written statement from the physiciandetailing the method, amount and time schedules by which the medication is tobe taken and (2) a written statement from the parent/guardian indicating thedesire that the school district assist the pupil in the matter set forth in thephysician's statement.
I request that the prescribed medication be administered tomy student and agree to hold Chaffey Joint Union High School District, itsofficers, and employees harmless from all liability or claims which might ariseout of these arrangements. I give mypermission for the school nurse to contact the physician for consultation asneeded.
___________________________________
Parent/guardian signature
PHYSICIAN'SAUTHORIZATION
Health condition for which medication isprescribed____________________________________
Name of Medication _______________________________
Time to be administered____________________ Method ofadministration_________________
Possible AdverseReactions_______________________________________________________
Start Date_______________________________ Date todiscontinue______________________
Comments____________________________________________________________________
Health condition for which medication isprescribed____________________________________
Name of Medication _______________________________
Time to be administered____________________ Method ofadministration_________________
Possible AdverseReactions_______________________________________________________
Start Date_______________________________ Date todiscontinue______________________
Comments_____________________________________________________________________
Health condition for which medication isprescribed____________________________________
Name of Medication _______________________________
Time to be administered____________________ Method ofadministration_________________
Possible AdverseReactions_______________________________________________________
Start Date_______________________________ Date todiscontinue______________________
Comments____________________________________________________________________
Name of Physician (please print)_________________________
PhysicianSignature____________________________________