HTML Preview Medication Requirement Checklist page number 1.
6/20/16
Medication Requirement Check List
STUDENT NAME_______________________________________________ DATE OF BIRTH_____________________
SUMMER CLASS_________________________HOME HIGH SCHOOL____________________ GRADE in 2016/17 ___
All medication must be brought to the school by a parent/guardian only. Students are not allowed to
bring in or drop off medications. Bring medications and check list to school by June 27th.
Before turning in any medications: complete the check list and sign below.
Authorization to Administer Medication Form
http://www.lwsd.org/SiteCollectionDocuments/About-Us/District-Forms/Student-
Health/Authorization-For-Administration-Of-Medication.pdf
Signed and dated by a licensed healthcare provider and parent.
This form is required for ALL medications: prescription, over-the-counter and self-carry.
Each medication requires a separate form.
Prescription Medications
Medication must be in the properly labeled pharmacy container. The pharmacy label MUST
MATCH the healthcare provider’s order exactly: Student name, Name of medication,
Medication dosage, and Time of medication
Over-the-Counter Medications
All over-the-counter medications (Tylenol, Advil, Benadryl, etc.) must have the student's name
written on the container in bold marker. The healthcare provider's order MUST MATCH the
medication exactly. Example: liquid vs. tablet, correct mg. per tablet. Benadryl should be in
single dose packets, not large elixir bottles.
Medication Expiration Date: __________________________________
IHP/ECP:
**If your child has a life threatening medical condition (allergy, asthma, diabetes, seizure,
cardiac condition), then an Individual Health Plan/Emergency Care Plan is required to be
signed and in place before they start school. Please include this in your packet on the first day
of school. Forms can be down loaded from the LWSD.org web site:
http://www.lwsd.org/Parents/Student-Health/Pages/Student-Health-Forms.aspx
Please bring this form, the Medication Authorization Form, and the student's medication to school in a
1-gallon clear Zip Lock bag. Write the student's “last name, first name” on the top left corner of the bag
in permanent marker. Bags will be provided if needed.
I verify that the above requirements have been met.
Parent Signature _______________________________ Date____________________