Medication Consent Form – Rapid City Area Schools

District Code: JHCD-E1
Student Name*
DOB
Grade
Teacher
I authorize the RCAS school nurse or UMAs (unlicensed medication aides) of _________________________School to administer the following to my child:*
Medication*
Dose*
Time: (check and fill in correct time/frequency/reason for medication)
Fill in one of the following:
1. Medication at ____________________________(time/frequency) for _______________________________ (problem/diagnosis)
2. Medication every ____________________(frequency) as needed for ___________________________ (problem/diagnosis)
3. Medication to control asthma or reactive airway disease every 4 hours as needed.
Prescribed by (if prescription) __________________ Phone: ______________
* 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.
Authorization start date: _______________
Authorization end date: _______________
- End of School
Parent/Guardian Name*
First Last
By check this box, you are electronically consenting to the information on this form.*
- Yes, I give consent
Date:*
Rapid City Area School District No. 51-4, Rapid City, South Dakota RCAS
RCAS Form 03-232