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This form is to be completed and
submitted for students that require prescription
medication while at PCC. Both parent and licensed
prescriber�s sections must be
completed and submitted no later than May 30, 2007.
PARENT SECTION:
Student�s name
___________________________________________Date of Birth _______
Last
First
Middle Initial
I consent to have the PCC Nurse, or designee, administer the
medication prescribed by:
_____________________________________to__________________________________
(licensed prescriber�s name)
(student�s name)
I give the PCC nurse permission to
share information relevant to the prescribed medication
administration as she determines appropriate for my child�s health
and safety. I understand that
any medication that is not picked up by the close of the last day of
the PCC Program will be
destroyed.
________________________________________________________
____________
(parent/guardian�s signature)
(date)
I give my child permission to
self-administer his/her medication if the PCC nurse determines that
it is safe and appropriate: ____Yes ____ No
LICENSED PRESCRIBER SECTION:
Child�s name_____________________________________________ Date of
Birth _______
1. Medication_________________________Route of
Administration____________________
Dosage____________Frequency____________Time(s) of
Administration______________
Side effects or special
instructions _____________________________________________
Date of order____________Discontinuation
Date_________________________________
2. Medication_________________________Route of
Administration____________________
Dosage____________Frequency____________Time(s) of
Administration______________
Side effects or special
instructions _____________________________________________
Date of order____________Discontinuation
Date_________________________________
3. Medication_________________________Route of
Administration____________________
Dosage____________Frequency____________Time(s) of
Administration______________
Side effects or special
instructions _____________________________________________
Date of order____________Discontinuation
Date_________________________________
4. Medication_________________________Route of
Administration____________________
Dosage____________Frequency____________Time(s) of
Administration______________
Side effects or special
instructions _____________________________________________
Date of
order____________Discontinuation
Date_________________________________
Consent for self-administration provided the PCC nurse determines it
is safe and appropriate.
____Yes ____ No
________________________________________________________________________
(signature of licensed prescriber)
(date)
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