AUTHORIZATION FOR MEDICATION/PROCEDURE TO BE ADMINISTERED AT

SCHOOL AND AT OFF-CAMPUS SCHOOL SPONSORED EVENTS

PART A
Parent/Legal Guardian to Complete
Name of Student: Date of Birth: Grade/Teacher:
I grant permission for the school nurse or a delegated staff member to administer medication/treatment to my child
at school as indicated by my child’s physician accordingly below. I understand that I must provide any prescribed
medication in its original container/package dispensed by the pharmacist.

I also acknowledge, in accordance with the Nurse Practice Act, the need and give permission for appropriate
communication between the school nurse and the medical prescriber related to the medication(s)/treatment(s) in
question to enable the nurse to administer safe and effective care. This includes communication concerning the
prescription/treatment itself, implementation of the prescription/treatment in school, student response to the
medication/treatment, and other pertinent issues related to the student’s diagnosis, condition, or medication/
treatment.

Parent/Legal Guardian Signature Parent/Legal Guardian (Printed Name) Today’s Date

PART B
Physician to Complete

Current Diagnosis(es):

PHYSICIAN MEDICATION AND/OR TREATMENT ORDERS: (Please specify)

Medication/Treatment Dosage Time/Frequency

Special Instructions:

Physician Signature Physician (Printed Name) Today’s Date

Physician Phone Number

BV‐111
Adapted from Guidelines for Medication Administration in Kansas Schools Revised 5/3/2017

AUTHORIZATION FOR SELF-ADMINISTRATION OF MEDICATION FOR

 ASTHMA/ALLERGIES K-12 AND INSULIN FOR GRADES 6-12
PART A
Parent/Legal Guardian to Complete
Name of Student: Date of Birth: Grade/Teacher:
The above student has been instructed on self-administration of medication, and I hereby give my permission for
him/her to administer at school as ordered the medication(s) listed below. I understand that it is my responsibility to
furnish this medication. I acknowledge that the school incurs no liability for any injury resulting from the self-
administration of medication and agree to indemnify and hold the school, and its employees and agents, harmless
against any claims relating to the self-administration of such medication.

I also acknowledge, in accordance with the Nurse Practice Act, the need and give permission for appropriate
communication between the school nurse and the medical prescriber related to the medication(s)/treatment(s) in
question to enable the nurse to administer safe and effective care. This includes communication concerning the
prescription/treatment itself, implementation of the prescription/treatment in school, student response to the
medication/treatment, and other pertinent issues related to the student’s diagnosis, condition, or medication/
treatment.

Parent/Legal Guardian Signature Parent/Legal Guardian (Printed Name) Today’s Date

PART B
Physician to Complete
Current Diagnosis(es):
Medication Purpose Dosage Time/Frequency

Conditions & Special Circumstances for use:

This student is authorized to self-administer and has been instructed in self-administration of this
medication. He/she has the skill, judgment and maturity to self-administer this medication.

Physician Signature Physician (Printed Name) Today’s Date

Physician Phone Number

PART C: School Nurse to Complete

School Nurse Review of order and procedure with student. Completed satisfactorily:
Date of Review

BV‐111A
Adapted from Guidelines for Medication Administration in Kansas Schools Revised 5/3/2017

AUTHORIZATION FOR MEDICATION/PROCEDURE TO BE ADMINISTERED AT

SCHOOL AND AT OFF-CAMPUS SCHOOL SPONSORED EVENTS
 PART A
Parent/Legal Guardian to Complete
Name of Student: Date of Birth: Grade/Teacher:
I grant permission for the school nurse or a delegated staff member to administer medication/treatment to my child
at school as indicated by my child’s physician accordingly below. I understand that I must provide any prescribed
medication in its original container/package dispensed by the pharmacist.

I also acknowledge, in accordance with the Nurse Practice Act, the need and give permission for appropriate
communication between the school nurse and the medical prescriber related to the medication(s)/treatment(s) in
question to enable the nurse to administer safe and effective care. This includes communication concerning the
prescription/treatment itself, implementation of the prescription/treatment in school, student response to the
medication/treatment, and other pertinent issues related to the student’s diagnosis, condition, or medication/
treatment.

Parent/Legal Guardian Signature Parent/Legal Guardian (Printed Name) Today’s Date

PART B
Physician to Complete

Current Diagnosis(es):

PHYSICIAN MEDICATION AND/OR TREATMENT ORDERS: (Please specify)

Medication/Treatment Dosage Time/Frequency

Special Instructions:

Physician Signature Physician (Printed Name) Today’s Date

Physician Phone Number

BV‐111
Adapted from Guidelines for Medication Administration in Kansas Schools Revised 5/3/2017

AUTHORIZATION FOR SELF-ADMINISTRATION OF MEDICATION FOR

ASTHMA/ALLERGIES K-12 AND INSULIN FOR GRADES 6-12
 PART A
Parent/Legal Guardian to Complete
Name of Student: Date of Birth: Grade/Teacher:
The above student has been instructed on self-administration of medication, and I hereby give my permission for
him/her to administer at school as ordered the medication(s) listed below. I understand that it is my responsibility to
furnish this medication. I acknowledge that the school incurs no liability for any injury resulting from the self-
administration of medication and agree to indemnify and hold the school, and its employees and agents, harmless
against any claims relating to the self-administration of such medication.

I also acknowledge, in accordance with the Nurse Practice Act, the need and give permission for appropriate
communication between the school nurse and the medical prescriber related to the medication(s)/treatment(s) in
question to enable the nurse to administer safe and effective care. This includes communication concerning the
prescription/treatment itself, implementation of the prescription/treatment in school, student response to the
medication/treatment, and other pertinent issues related to the student’s diagnosis, condition, or medication/
treatment.

Parent/Legal Guardian Signature Parent/Legal Guardian (Printed Name) Today’s Date

PART B
Physician to Complete
Current Diagnosis(es):
Medication Purpose Dosage Time/Frequency

Conditions & Special Circumstances for use:

This student is authorized to self-administer and has been instructed in self-administration of this
medication. He/she has the skill, judgment and maturity to self-administer this medication.

Physician Signature Physician (Printed Name) Today’s Date

Physician Phone Number

PART C: School Nurse to Complete

School Nurse Review of order and procedure with student. Completed satisfactorily:
Date of Review

BV‐111A
Adapted from Guidelines for Medication Administration in Kansas Schools Revised 5/3/2017
 BLUE VALLEY SCHOOL DISTRICT #229
HEALTH ASSESSMENT FOR CHILDREN AND YOUTH
Confidential Child Health Record (To be released only on signature of parent/guardian)

Student Name: Birthdate:

PHYSICAL EXAMINATION To be completed by health care provider approved to perform health assessments.

Height Weight Age of onset of

menses?
Pulse Blood Pressure Lead
Urinalysis Sickle Cell Other
Tuberculosis Head Circumference

Response Codes 0 = No Significant Findings 1 = Significant Findings

Code Description of Findings
General Appearance
Integument
Head – Neck
EENT
Oral / Dental
Thorax
Breasts
Cardiovascular
Abdomen
Musculoskeletal
Genitourinary
Neurological

SCREENING

1. Nutritional Evaluation (all ages – each screen) (all that apply) Nutrition/WIC questionnaire available from
(913) 296-0092
Enrolled in WIC Receiving Vitamin Supplement with Iron
Fluoride Supplement Receiving Vitamin Supplement without Iron
Food Intake Review Results:
milk/milk products (breastfed / type of formula)
fruit / vegetables
meat, beans, eggs
breads, cereals
2. Development: Type of screen Results
3. Speech: Type of screen Results
4. Hearing: Type of screen Results
Date of last screen
5. Vision Type of screen Results
Date of last screen

Significant Assessment Findings: Anticipatory Guidance: (circle those discussed)

1. Safety/poisons 8. Lifestyle
2. Nutrition 9. Development
3. Parenting 10. Behavior
4. Family planning 11. Sexuality
5. Discipline 12. Dental
Recommendations: 6. Immunizations 13. Other
7. Hygiene

Physician’s Signature: ____________________________________________________ Date: _________________________________

BV – 163- revised 1/112019