Medication Form

Crown of Life Lutheran School is authorized to give the following medication(s) to the above student.

All medications need parent’s signature. Returned Form to School Office when needed 

ALL MEDICATIONS MUST COME IN ORIGINAL PACKAGING

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As a part of the Wisconsin Statute Chapter 118.29, schools are required to have permission from a parent to administer medications at school. As part of the authorization form, schools may contact the medical provider and parent with questions regarding the medication administration including clarification regarding dosage, side effects or indication of the medications listed above with parent permission.

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(Prescriptions Only)

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If your child is in need of emergency medications such as an asthma inhaler or Epinephrine injection you must fill out the proper emergency care plan forms and return to the school office.

Additional forms are available in the school office.

  •  I understand that non-medically trained school personnel will give medication. 
  •  I agree to hold the Crown of Life Lutheran School, its employees and agents, who are acting within the scope of their duties, harmless in any and all claims arising from the administration of this medication at school.
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THE MEDICATION FORM MUST BE COMPLETED FOR ANY "OVER THE COUNTER MEDICATIONS OR ANY PRESCRIPTION MEDICATIONS"

** Medication forms are available in the school office. **

When any medicine, whether it is OTC (over the counter) or a PRESCRIPTION, is sent to school because of an illness or for allergies, a new State Law requires us to follow the procedure listed below.

1. Notify the classroom teacher and the school secretary.

2. Completion of a Medication Form must be completed. Prescription medication can’t be accepted without written instructions and parental permission.

3. All prescription medications must be in their original pharmacy containers, which are properly labeled with the following information: Student’s name, Name of medication, and Dose/time. Ask the pharmacist to dispense medication in two containers – one for school and one for home.

4. All non-prescription medication (over the counter) must be in its original manufacturer’s container with the student’s name affixed to the container, dosage amounts and times listed on the container. EACH CHILD must have their own medication and siblings may not share medication from the same bottle or container, and a parent authorization form is needed for each child.

5. ALL medicine will be locked up during the day. That includes all OTC medications, i.e., inhalers, Tylenol, etc. Medicine will not be kept in the hallway in a backpack!

6. The school secretary will give the medicine to the student at the appropriate time. 7. If there is any change as to how or when the medicine should be given, a new form must be completed and given to the classroom teacher or school secretary. 8. Remember, teachers or the school secretary cannot dispense any medication if the above procedures have not been met.

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