Denton Independent School District
Parent/Physician Request for Administration of Medication by School Personnel
Parents have the primary responsibility of giving medicine to their child at school, and may come to school to give medicine at any time, after checking in at the school office.
Requests for the administration of medications by school personnel may be made as follows: ( in accordance with
Education Code 22:052) Texas
1. A separate request form is to be completed for each medication, and a new request made for each change in medicines or dosages.
2. Only those medications that cannot be given outside school hours will be administered. Most three times a day medicines can be given before and after school. (Prescriptions can be written so that doses are not necessary during school hours. Please discuss this with your doctor.)
3. Elementary students will be given non-prescription, over-the-counter (OTC) medicine by school personnel only with a Dr’s prescription. The doctor may sign this medication sheet or send written or faxed instruction for administration to the school nurse. Middle school and high school students may, with their parents’ permission (doctor’s order not required) carry small amounts (no more than two days’ supply) of OTC medicine for self-administration; this medicine must be in the original container labeled with the student’s name, and may not be shared with other students. No dietary supplements, herbal remedies, vitamins, performance boosters, etc. are allowed on school campuses or at school activities. Any exceptions to this practice will be made in writing only after discussion with the student’s doctor, parents, and school nurse. Any medicine in other than the original container is considered contraband, subjecting the student to disciplinary measures.
4. All medication must be in the original, properly labeled container, accompanied by this completed form. Please ask your pharmacist to dispense two labeled bottles of medication: one for home and one for school. Changes in dosages require new labels and new parent request forms.
5. Elementary and Middle School medications are distributed in the health room/office. Please encourage your child to take the responsibility to go to the office at the prescribed time. Elementary and Middle School students may carry inhalers (prescription and OTC) only with a doctor’s order.
- Unused medication will be discarded at the end of the school year. We highly encourage parents to pick up any unused medication rather than sending it home with children. We will send medicine home with a student only with parent written request.
For safety reasons, no first doses of any medicine will be administered at school. All information below must be completed and form signed before medication will be given by school personnel.
Date of Request_________________________________ Medication to be given from (start date)________________________until (end date)____________________________
Student’s Name__________________________________________________ Grade_________________ Teacher or Team # ________________________________________
Name of Medication ________________________________ Exact dosage in mg,puffs,etc. _____________________________ Time(s) to be given at school _______________
Reason this medicine is required (for what condition?) __________________________________________________________________________________________________
If given on an “as-needed” basis, the following* information must also be provided.
*Indicate shortest intervals between doses ___________________________________ *Maximum number of doses during school day__________________________________
*Signs and /or symptoms for which the medicine is to be given ___________________________________________________________________________________________
Special instructions, precautions, or side effects ________________________________________________________________________________________________________
Physician’s Name __________________________________________________ Office Phone _____________________________ Fax ______________________________
I, the undersigned parent/guardian of _________________________________________________________________ request the above medication be administered to my child.
(Student’s Name) I also give permission to my child’s teacher to administer this same
medication as prescribed above on field trips during this school year.
(Home) (Work or cell)
**Signature _____________________________________________________________(Physician) **(A properly labeled prescription container will be accepted as proof of physician's order.