• District Code: JHCD-E1

  • Time: (check and fill in correct time/frequency/reason for medication)

  • Fill in one of the following:

  • * Prescribed medication must be provided in the original container stating the student’s name, medication name, dosage, frequency, pharmacy and physician’s name.

  • * Over the counter medications must be in the original container and an age appropriate form/dose.

  • * “Natural remedies”, herbs, vitamins, dietary supplements and homeopathic medications are considered a prescription medication and require a physician’s order.

  • * Cough medications must be in the original container. Cough drops preferred in lozenge form.

  • * The first dose of any medication must be given by parent/guardian.

  • * Parent/guardian is responsible to pick up medications from school.

  • I absolve the school personnel of all responsibility for any unforeseen development/reaction due to the administration of the above-named medication. I hereby give consent for the school nurse to communicate with my child’s health care provider as needed regarding this medication. It is the responsibility of the child to come to the office to take his/her medication.

  • Rapid City Area School District No. 51-4, Rapid City, South Dakota RCAS

  • RCAS Form 03-232