2008-2009

WYLIE Independent School District

Parent/Physician Request for

Administration of Medication by School Personnel

Date of Request: ________________________________________ School: __________________________

Student’s Name: ________________________________________ Teacher/Grade: __________________

Medication: _____________________________________________ Dosage: ________________________

Is this the initial dose of a new medication that has not been previously administered to your child? YES NO

Times to be Administered: ________________________________ Dates to Administered: ____________

Condition for which medication is required: __________________________________________________

Special Instructions/Precautions/Side Effects of medication on your child: ________________________

________________________________________________________________________________________

Physician’s Name: _______________________________________ Phone: _________________________

*Physician’s Signature: ___________________________________________________________________

My signature below indicates that I request that WISD staff administer the medication specified above to my child,

and I am giving permission for WISD staff to contact the physician for additional information, if needed.

Parent/Guardian Signature: _______________________________ Email: __________________________

Parent’s Home Phone: ___________________________________ Work Phone: _____________________

*Physician’s signature is required to administer over-the-counter medications for more than 10 consecutive school days from the date of the original request.

FOR OFFICE USE ONLY!

Medication Count:

Date

# Pills

Counter’s Signature

Witness Initials

Date

# Pills

Counter’s Signature

Witness Initials

Comments (Indicated by * on back of form):

Date

Comments

Date

Comments

Signature of Person Administering Medication Initials

________________________________________________________________ ___________________

________________________________________________________________ ___________________

________________________________________________________________ ___________________

CHARTING CODES

A	DC	FT	H	OOM	SF	*
Absent	Discontinued	Field Trip	Hold	Out of Medication	Sent For	Comments

* Indicates Comments on front of form