BELLOWS FALLS UNION HIGH SCHOOL
PO Box 429
Bellows Falls, Vermont 05101
(802)463-3944 FAX: (802)463-9322
CHRISTOPHER HODSDEN
PRINCIPAL
PRESCRIPTION MEDICATION ORDER AND PERMISSION
To be returned to the School Nurse
Jennifer Joy, RN
Student Name__________________________________________________
Grade___Date of Birth__________Phone number___________
**********************PHYSICIAN SECTION********************
Medication____________________________________________________
Strength__________________ Route_______________Time____________
Today’s date_________________ Duration of order___________________
Reason for giving_______________________________________________
Physician’s Signature____________________________________________
Physician’s phone number________________________________________
*****************PARENT/GUARDIAN SECTION****************
I give permission for my child _____________________________________________________________
to take the above prescription from the school nurse or the school nurse’s delegate as ordered. I give permission for the school nurse to confer with my child’s physician in regards to this medication as necessary.
Signature of Parent/Guardian_________-_____________________________________________________Medication will not be given at school until the school receives this completed form with the prescribed medication in a container appropriately labeled by the pharmacy or physician.
An adult must deliver medications to the school nurse or designee. STUDENTS MAY NOT CARRY MEDICATION DURING THE SCHOOL DAY.
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