WALLKILL VALLEY REGIONAL HIGH SCHOOL
BOARD OF EDUCATION
Student's Name___________________________________D.O.B._________Date_________________
Parent's Name____________________________________Telephone Number Work_______________
Home__________________
To be completed by Physician:
I am recommending that the above mentioned student be allowed to self-administer the following medication
___________________________________________________________________________
Name and purpose of medication:____________________________________________
Identification of Chronic Medical Problem:_________________________________
Prescribed dosage to be taken:_____________________________________________
Length of time medication must be taken:___________________________________
Possible Side Effects and/or special precautions to be taken_______________
___________________________________________________________________________
Conditions under which self-administration will take place:
__________Independently. Child must have had training and be profcient in self-adminstering medication.
Trainer's Name_________________________Date____________
__________Under the supervision of the School Nurse.
Medication should be ____stored in the health office.
____ in the possession of the student.
_________________________ ____________________
Physician's Name Physician's Signature
_________________________ _____________________
Telephone Number Date
To be completed by Parent/Guardian:
I give my permission for my child to self-administer the medication described above.The
Wallkill Valley Regional High School shall incur no liability as a result of any injury arising from the self-administration of medication by
the pupil and that the parents or guardians shall indemnify and hold harmless the district
and its employees or agents against any claims arising out of the self-administration of medication by the pupil. I will notify the school nurse if the medication is no
longer required or self-administration is no longer directed by the physician.
_______________________________
Parent/Guardian Signature