Jerome Joint School District No. 261 

Physician’s Order for Prescription Medication Given in School 3510F1

Jerome School District #261 - District Nurse Services

830 10th Ave E • Jerome, Idaho 83338

Telephone (208) 324-3361 • FAX (208) 324-3362

Physician’s Order for Prescription Medication Given in School

Note to Parent/Guardian:

The Provision of medications to students during school hours is discouraged. However, Jerome School District recognizes those special cases where a student’s physician documents a need for in-school dosing. 

1. It is the policy to maintain a signed order for medication that the school personnel are asked to dispense during school hours. This form must be completed BEFORE any medication(s) can be given. This form must be renewed each school year.

2. The medication must be sent to school in its ORGINAL container with ORGINAL pharmacy label with student’s name, name of drug, name of prescriber, pharmacy name, Rx number, date of prescription and expiration date.

3. The district shall incur no liability as a result of any injury arising from the self-administration of medication. By signing, parent/guardian is agreeing to indemnify and hold harmless the district and employees against any claims arising out of the self-administration of medication by your student.

Student’s Name: _______________________________________ Date of Birth: _______________

School: ______________________________________________ Grade: _____________________

To be completed by the Physician or Authorized Prescriber

Diagnosis: _______________________________________________________________________

Name of Medication: _______________________________________________________________

Form of Medication/Treatment:

____Tablet/Capsule _____Liquid _____ Inhaler _____ Injection _____Nebulizer _____Other

Instruction: _______________________________________________________________________

Restrictions and/or Other Important Side Effects:

_____None anticipated

_____Yes. Please Describe: ________________________________________________________

Storage Requirements: _____None _____Refrigerate

_____Immediate access to this medication by the student:

_____Be kept with the student at all times _____Be kept in the school’s office

_____Be kept in student’s desk _____Be kept in student’s classroom

Physician’s/Prescriber’s Signature: ___________________________________ Date: _______________

Address: __________________________________________________ Phone #: __________________

To be completed by Parent Guardian: 

I give my permission for my child to receive the above medication at school according to school policy.

Date: __________ Signature: _______________________________________________________

Policy History:

Adopted on: 04/28/2009

Revised on: 02/24/2015

Revised on: 05/27/0225