Date of report

Hartford Public Schools
Nursing Services
Authorization for the Administration of Medicine by School Personnel

The Connecticut State Law and Regulations 10-212(a) require a written medication order of an authorized prescriber, (physician, dentist, advanced
practice registered nurse or physician's assistant) and parent/guardian written authorization, for the nurse, or in the absence of the nurse, a
designated principal or teacher to administer medication. Medications must be in the original properly labeled container and dispensed by a

Prescriber's Authorization
Condition for which drug is being administered ALLERGIES NO__ YES__ (specify) ___________________________________
Medication shall be administered from May 22, 2014_ during overnight Cape Cod field trip.

Use for Prescriber's Stamp
Parent/Guardian Authorization
I hereby request that school personnel administer the above ordered medication to my child on field trips.
I understand that I must provide all medication for the field trip. No medication will be sent
from the school nurse’s office. Medications not picked up by the parent upon return of the
trip to the school will be discarded.
Parent/ Guardian Signature
____________ Cell #_____________________
Parent email: ________________________________________________________________________________
Please read and sign below.
Parent will administer medication that their child normally takes in the morning at
home before the field trip on the morning that the field trip departs.
I understand that medication must be given to the nurse NO LATER than
____May 10, 2014______________________ NO EXCEPTIONS.
Medication forms must be given to the nurse at school no later than
___March 25, 2014______________________. NO EXCEPTIONS.
Medication must be in the original prescription bottle or original packaging if the
medication is over the counter.
I understand that every medication that my child needs on the trip must have a
doctor’s signed order and my signature on the order form. This includes all over the
counter medications.

A SEPARATE FORM is needed for EACH medication.
Verbal orders will not be honored.
If my child becomes ill during the trip, no medication will be administered without a
completed, signed form.
Do not FAX forms to the nurse. Bring in original forms from your doctor.

Parent Signature Date


Alcohol service provider conditions

__________________________________________________________________________________________ Note: This is to be filled out only if a child is bringing medication to program. __________________________________________________________________________________________ I hereby authorize and instruct ______________________________or another trained staff/volunteer to administer medication id

Vincristine case

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