PARENT/GUARDIAN AND PHYSICIAN PERMISSION FOR PRESCRIPTION MEDICATION Name of Student _____________________________________________ Birthdate ________________________ School ________________________________________ Grade/Teacher_________________________________ To the Physician: According to the State of Wisconsin Medical Examining Board and the Delavan-Darien School District, the following information must be completed for school personnel to dispense or administer medications. Physician Name ___________________________________ Telephone number ____________________________ Medication(s) _________________________________________________________________________________ Dosage(s) ___________________________________________________________________________________ Time(s) of day to be administered________________________________________________________________ Length of time to be administered ________________________________________________________________ Special instructions ____________________________________________________________________________ I am willing to accept direct communication from the school nurse about dispensing or administering the medication. __________________________________________________________ Physician Signature

_______________________________ Date

To the Parent/Guardian: I request and authorize personnel from the Delavan-Darien School District to administer medication to the above named student. In the event more information is needed regarding this medication, I authorize the school nurse to contact my child’s physician.

Parent/Guardian signature ________________________________________________ Date _________________ Please fax this form to the following school: _____ Darien School-FAX: 262-724-4147 _____ Turtle Creek School-FAX: 262- 728-6951 _____ Wileman School-FAX: 262-728-6956

_____ Delavan-Darien High School-FAX: 262-728-9713 _____ Phoenix Middle School-FAX: 262-728-0359

PARENT/GUARDIAN AND PHYSICIAN PERMISSION FOR PRESCRIPTION MEDICATION Name of Student _____________________________________________ Birthdate ________________________ School ________________________________________ Grade/Teacher_________________________________ To the Physician: According to the State of Wisconsin Medical Examining Board and the Delavan-Darien School District, the following information must be completed for school personnel to dispense or administer medications. Physician Name ___________________________________ Telephone number ____________________________ Medication(s) _________________________________________________________________________________ Dosage(s) ___________________________________________________________________________________ Time(s) of day to be administered________________________________________________________________ Length of time to be administered _________________________________________________________________ Special instructions ____________________________________________________________________________ I am willing to accept direct communication from the school nurse about dispensing or administering the medication. ___________________________________________________________ Physician Signature

_______________________________ Date

Padres/Tutores: Yo solicito y autorizo al personal del Distrito Escolar Delavan-Darien para que le administren medicamento al estudiante arriba mencionado. En el evento que se requiera más información referente a este medicamento, yo autorizo a la enfermera escolar para que contacte al médico de mi estudiante.

Firma del Padre/Tutor ________________________________________________ Fecha _________________ Please fax this form to the following school: _____ Darien School-FAX: 262-724-4147 _____ Turtle Creek School-FAX: 262-728-6951 _____ Wileman School-FAX: 262-728-6956

_____ Delavan-Darien High School-FAX: 262-728-9713 _____ Phoenix Middle School-FAX: 262-728-0359