TROY SCHOOL DISTRICT NON-PRESCRIPTION SELF-CARRY/ADMINISTER AUTHORIZATION
(This is the accessible text for the downloadable Non-prescription self-carry/administer authorization form. Download the form here: Troy School District Non-Prescription Self-Carry/Administer Form for Download
This form is for FDA-Approved topical over-the-counter medications. A student may self-carry/self-administer provided this form is completed by the parent/legal guardian. This form is also for high school & middle school students allowed to carry non-prescription medication to school and responsibly self-medicate provided the form is completed by the parent/legal guardian. For all prescription medications or any medication that must be administered by TSD Staff, please use the Authorization for Medication form which must be completed and signed by the student’s physician AND parent/legal guardian.
- Student Name: (Fill in the blank)
- Grade: (Fill in the blank)
- Date of Birth: (Fill in the blank)
To be completed by the Parent or Legal Guardian: ONE MEDICATION PER FORM Name of non-prescription medication:
- Reason for medication: (Fill in the blank)
- Start Medication on
- (Check box) Date from received
- (Check box) Other dates: (Fill in the blank)
- Stop Medication:
- (Check box) End of school year
- (Check box) Other date/duration: (Fill in the blank)
A student who has been approved for self-carry/self-medicate may have in his/her possession only the quantity of medication needed for that school day, unless otherwise approved, in writing, by the building administrator.
Students are prohibited from sharing or administering medication with or to each other. A building administrator may discontinue a student’s right to self-administer and self-possession if there is a misuse by the student. The above-named student is allowed to carry and self-administer non-prescription medication without the supervision or monitoring by school personnel.
Parent/Guardian Name: (Fill in the blank)
Relationship: (Fill in the blank)
Signature: (Fill in the blank)
Date: (Fill in the blank)
Revised 5/24/22: TROY SCHOOL DISTRICT MEDICATION PROCEDURES
- Medication Authorization is for the current school year only and will expire at the end of the school year.
- Written authorization and order completed and signed by the student’s physician and a parent/guardian is required before any medication can be given at school. Medications include prescription, over-the-counter, topical, eye or ear drops, nasal sprays or mists, and inhalers.
- Only one medication per form. A separate form is required for every medication.
- Medication administration during school hours will be permitted only when failure to do so will jeopardize the health of a student or the student would not be able to attend school if the medication or treatment were not available during school hours.
- Medications must be brought to school by the student's parent/legal guardian.
- Parents/legal guardians are responsible for checking the need for medication refills, including expired medications, and supplying the refills to the school in a timely manner.
- All medications must be in a container as prepared by a pharmacy, physician, or pharmaceutical company and clearly marked with the student's name, the name of the medication, the prescribed dosage, and requested time of administration.
- All controlled-substance medications will be counted and recorded in the presence of the parent/legal guardian when brought to school.
- Changes in dosage, frequency, or time of administration cannot be made without written instruction from a physician.
- Students in high school and middle school may self-carry/medicate prescription medications only if authorized by the physician and parent/guardian.
- Students in high school and middle school may self-carry/medicate non-prescription medications if authorized by the parent/guardian and the Non-Prescription Self-Carry/Self-Administer Form is completed.
- A student who has been approved for self-carry/medicate may have in his/her possession only the quantity of medication needed for that school day, unless otherwise approved, in writing, by the building administrator.
- Students who self-carry should never share their medication with anyone else.
- Designated staff will be administering medication.
- Administrators, counselors, teachers, and other appropriate staff will be made aware of your child’s condition and need for medication.
- The school will NOT be distributing lunch or afternoon medications on half days of school.
- Medication left over at the end of the school year or after a pupil has left the district shall be picked up by the parent/legal guardian. Any medication not retrieved by the parent/legal guardian will be disposed of within seven days of the last student day of school and documented by the individual who is responsible for administering medication.
- Please list all medications your child is currently taking, whether taken in the home or at school (optional): (Fill in the blanks)
- Parent Signature: (Fill in the blank)
- Date: (Fill in the blank)
End of Form
