CENTRAL COMMUNITY UNIT SCHOOL DISTRICT 301
Department of Student Support Services – Health Services Division
P.O. BOX 396, 275 South Street, Burlington, Illinois 60109
(847)464-6005 (847)-464-6021 Fax
Dear Parents / Guardians:
Medications are defined as either prescription or over-the-counter drugs.
Over-the-counter medications as well as prescription medications will be administered in school only when a “Meds-A” form has been completed by the parent / guardian and the physician.
If you feel your child might require a prescription or over-the-counter medication, like Tylenol, Motrin or other such medication, there must be a “Meds-A” form on file. One form must be completed for each medication and requires completion by both the parent / guardian and the physician. When this form is completed and filed in the school health office, the child will be administered the identified medication. The physician’s order for medication and thus the
Meds A form must be renewed annually or whenever a medication or dosage is changed.
The “Meds-A” form needs to be completed and submitted when a medication is brought to school. All medications need to be brought to school or back home by a parent or guardian.
Students are not permitted to transport medications, unless a specific order is written by the doctor that the student may carry their epipen or inhaler.
These procedures are for the protection of your child and for those administering the medications to Central District #301 students. A complete guideline for medication administration at school can be found in your student handbook. We appreciate your cooperation with this process and hope it will benefit both you and your child in knowing that medications are being safely administered. If you have any questions, please feel free to call.
Respectfully,
A. Bryant RN CSN L. Ramirez RN J. Lullo RN CSN S. Dossey RN
PV 847-464-6014 LL 847-464-6011 HBT 847-464-6008 CT 847-717-8000
Fax 847-464-6024 Fax 630-365-2283 Fax 847-464-6022 Fax 847-717-8006
S. Terlecki RN A. Jones RN C. Drafall RN CSN
PKMS 847-717-8103 CMS 847-464-6000 CHS 847-464-6027
Fax 847-717-8105 Fax 847-464-6023 Fax 847-464-6039
CENTRAL COMMUNITY UNIT SCHOOL DISTRICT 301
Department of Student Support Services – Health Services Division
P.O. BOX 396, 275 South Street, Burlington, Illinois 60109
(847)464-6005 (847)-464-6021 Fax
Meds A Form
To be completed by
parent or legal guardian:
Student’s Name_______________________________________ Birth date____________________
Address_____________________________________________ Phone #_____________________
School _________________________________ Grade________ Teacher__________________
Physician’s Name _______________________________ Physician’s Phone #_________________
(Please print) Physician’s Fax #___________________
I hereby grant permission for the above named school to administer the medication routine described below for the above named child. I further give the district nursing staff permission to be in contact with the prescribing practitioner with regard to the medication order and the response my child has to the medication.
________________________________________ ___________________________
Signature of parent / legal guardian Date
To be completed by Physician:
Name of medication________________________________________________________________
Dosage__________________________________ Time / Frequency ________________________
Diagnosis ________________________________________________________________________
Is this medication necessary in order to maintain the student at school? Yes No
May student carry this epi-pen or inhaler with them? Yes No N/A
Side Effects to be alert to: ___________________________________________________________
_________________________________________________________________________________
Further instructional remarks: _________________________________________________________
_________________________________________________________________________________
Dr’s. Signature______________________________________________ Date________________