Proud to Teach for Tomorrow

20650 Glenn St Elkhorn, NE 68022
Phone: 402-289-2579

Student Medication Form

This form is to be used for all medicine brought to school that is to be kept in the office and dispensed by trained school personnel. Please note the following prior to downloading and completing the form

  1. There are two sides to this form.
    1. The front side must be completed for all medication dispensed from the office.
      1. The physician must fill in the top portion completely, then sign and date it before medicine can be dispensed.
      2. The bottom portion must be completed by the parent. This includes the signature and contact information after the paragraph indicating that the parent requests this medication be given during school hours.
      3. The section described in #2 covers parent permission for all oral, inhaled, instilled, or topical medications to be given at school on a routine basis (a set time every day).
      4. The section at the very bottom must be completed by the parent when the medication prescribed is oral, inhaled, topical, or instilled and is to be given on a PRN or as needed basis.
    2. The back side is only to be completed when 2 other criteria are needed for medication to be given.
      1. The section at the top is only completed if the ROUTE of the medication prescribed is something other than oral, inhaled, topical, or instilled. Administration procedures will be attached and additional training is required of staff for these meds to be given.
      2. The final section is completed only if staff is to participate in specific monitoring that is requested by parents &/or physician. Specific instructions and training of staff are required if this section is needed.
  2. Students with diabetes, severe allergies, and asthma may carry their medications and equipment with them during the school day only if certain conditions are met and the paperwork is completed. Please talk with the school nurse if your student needs to carry his medications/equipment for these conditions only.

Student Medication Form