AUTHORIZATION FOR THE ADMINISTRATION OF MEDICATION
                                                BY SCHOOL PERSONNEL

Connecticut State Law (Connecticut General Statutes 10-212a1-7) requires a written

order from a physician or dentist licensed to practice medicine in this state and from a
childís parent or guardian in order for a school nurse or other trained school personnel
to administer medication in school or on a school field trip. All medicinal preparations,
prescription and/or non-prescription over-the-counter items, must be in the original,
correctly labeled container from the pharmacy or store. All medicinal preparations are
stored by the nurse in school. No more than a 45-day supply is to be stored in school.

PHYSICIAN'S OR DENTIST'S ORDER                          Date of Order _________

Name of Student__________________________       Date of Birth __________

Condition for which Medication is ordered ___________________________________
____________________________________________________________________

Name and strength of Medication _________________________________________
____________________________________________________________________

Student may SELF-ADMINISTER: AGE SPECIFIC 7th-12th Grade _____________

Amount of medicine to be administered each dose ____________________________

Method of administration ________________ Time of Administration ____________

Side effects; if any: _____________________________________________________

Plan for management of any side effects _____________________________________

Is this a controlled drug? ______ Duration of order: From _________ To _________

________________________________ / ______________________________
Printed Name of Physician                           Signature of Physician

Address__________________________   Telephone __________________

                                  PARENT / GUARDIAN AUTHORIZATION

To ______________________________                        Date ______________
I hereby authorize school personnel to administer the above medicinal preparation to
my child: ____________________________, as ordered by the physician or dentist.
I understand that the medicine must be provided in the original labeled container from

the pharmacy or store and must be brought to school by parent or other responsible

adult, NOT by student.  I understand that this medicinal preparation will be destroyed

if not taken home by me within one week following termination of the orderor one

week beyond the close of school.

Signature________________________ Relationship to child _______________
Address _______________________ Telephone ________________________

This order valid only during the current school year, for the length of time specified.