Santa cruz county outdoor science school

Santa Cruz County Outdoor Science School
Physician and Parent Authorization to Administer Medication
**No medication will be given without Parent AND Physician permission**
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SECTION I
TO BE COMPLETED BY THE PARENT OR GUARDIAN
Nonprescription Medications at the Outdoor Science School

Occasionally it is necessary to provide students with nonprescription medications while at the Outdoor Science School. The over-the-counter medications listed below or their generic equivalents are provided for this purpose. Please check the “Yes” box to indicate your permission for the listed medications to be administered by the Health Supervisor, or an authorized staff member. If your child may not receive any medication while at the Outdoor Science School, check the “No” box. If your child may receive only some medications, cross out the medications your child may not receive and check the “Yes” box to indicate permission for medications not crossed out. In order for your child to receive the over the counter medications for which you have checked “yes”, his/her physician must also authorize with a signature in Section II on the reverse side of this form. ANALGESICS Sunblock □ YES My child has permission to receive the medications listed above at the Outdoor Science School. □ NO My child does not have permission to receive over-the-counter medications at the Outdoor Science School. Comments:_________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
ALL medication sent with your child, both prescription and non-prescription, must be in the original container. The
container must be clearly labeled with the following information:

1. STUDENT’S NAME
2. PHYSICIAN’S NAME
3. NAME OF MEDICATION
4. DOSAGE (how much and when)
Please package enough for 2 extra days in case of emergency, accidental loss or damage. It is important that the student
continue to take his/her medication while at the Outdoor School. Medication must be given to your child’s classroom teacher
for delivery to the Outdoor Science School Health Supervisor. DO NOT pack your medicines in your child’s luggage.
REQUEST OF ADMINISTRATION OF MEDICATION BY SCHOOL PERSONNEL
The Board of Education recognizes that certain students may need to take prescribed or over-the-counter medication during their stay at the Outdoor
Science School. The Health Supervisor, or other persons designated by the administration shall assist such students in taking their medication. The
Outdoor School is not legally required to administer medication to the children participating in the program. However, at the request of the
parent/legal guardian, with proper authorization, the Outdoor School will administer medication in an effort to carry out the wishes of the parent/legal
guardian and the recommendations of a physician.
I request that my child be assisted by authorized persons in taking the described medications listed in Section I and Section II (as applicable) at the
Santa Cruz County Outdoor Science School in compliance with established policies and procedures.
I understand that medication may be dispensed by someone other than a registered nurse. I hereby agree to hold the Santa Cruz County Office of
Education and its officers, agents, and employees harmless from any and all liability which may arise out of SCCOE’s performance under this
agreement.
SIGNATURE OF PARENT/LEGAL
GUARDIAN______________________________________________DATE_____/_____/__________
********************SEE REVERSE SIDE********************
IN ORDER FOR YOUR CHILD TO BE AUTHORIZED TO RECEIVE THE MEDICATIONS
LISTED ABOVE, HIS/HER PHYSICIAN MUST ALSO SIGN IN SECTION II.
Physician and Parent Authorization to Administer Medication (cont.)
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SECTION II: TO BE COMPLETED BY CHILD’S PHYSICIAN
Prescription and Regularly Taken Nonprescription Medications
Note to the child’s Physician: Please review SECTION I of this form, complete SECTION II if applicable and sign below.
Precautions, Special Instructions, Possible Adverse Effect(s), or comments: For students with asthma or severe (anaphylactic) allergies, please indicate if they have your permission to carry their inhaler and/or epi-pen on their person and use as needed while attending the Santa Cruz County Outdoor Science School. □ Yes – this student has my permission to carry their inhaler and/or epi-pen on their person □ No – This student may not carry their inhaler and/or epi-pen on their person. His/her medication must be on the person of an adult guardian at all times. The above named student for whom the medication in SECTION I and SECTION II of this form
are prescribed is under my care.
Address: (Number, Street Name, Suite or Room Number, City, State and Zip Code)

Source: http://www.osp.santacruz.k12.ca.us/download/authorization_administer_medication.pdf