St. Johns County School District<\/strong><\/p>\n Rev. 07\/2026<\/strong><\/p>\n Student Name:<\/strong> [Student Name]<\/p>\n Date of Birth:<\/strong> [Date of Birth]<\/p>\n School:<\/strong> [School]<\/p>\n Teacher\/Grade:<\/strong> [Teacher\/Grade]<\/p>\n List Known Allergies:<\/strong> [Allergies]<\/p>\n All information must match the prescription label!<\/strong> All medication must be properly labeled and in original containers. Complete one form for each medication\/treatment to be administered. A new form must be completed if the dosage of a medication changes at any time.<\/p>\n Nursing services are recommended for the care of this student during the school day. It is necessary for the following medication\/treatment to be given in school and during school-sponsored activities. I am aware that non-medical personnel may administer this medication\/treatment.<\/p>\n Physician Address:<\/strong> [Physician Address]<\/p>\n Physician\u2019s Phone:<\/strong> [Physician Phone]<\/p>\n Fax:<\/strong> [Fax]<\/p>\n Physician\u2019s Signature:<\/strong> (required for all medications) [Signature]<\/p>\n Date:<\/strong> [Date]<\/p>\n I authorize my child\u2019s school nurse to assess my child regarding his\/her special health care needs and to discuss these needs with my child\u2019s physician as needed throughout the school year. I understand this is for the purpose of generating a health care plan for my child. I understand I may withdraw this authorization at any time and that this authorization must be renewed annually.<\/p>\n As the parent or guardian of the student named above, I request that the principal or principal\u2019s designee assist in the administration of medication\/treatment prescribed for my child.<\/p>\n I understand that under provisions of Florida Statute 1006.062, there shall be no liability for civil damages as a result of the administration of medication when the person administering such medication acts as an ordinarily reasonable, prudent person would have acted under the same or similar circumstances. I also grant permission for school personnel to contact the physician listed above if there are any questions or concerns about the medication. I have read the guidelines and agree to abide by them. I authorize the physician to release information about this condition to school personnel.<\/p>\n Parent\/Guardian Signature:<\/strong> [Signature]<\/p>\n Print Name:<\/strong> [Print Name]<\/p>\n Phone Number:<\/strong> [Phone Number]<\/p>\n Date:<\/strong> [Date]<\/p>\n Florida law states a student may carry a metered dose inhaler or epinephrine delivery device on his\/her person and self-administer while in school with approval from his\/her parents and physician.<\/p>\n The above-named child may carry and self-administer his\/her emergency medication.<\/p>\n Parent\/Guardian Signature:<\/strong> (required) [Signature]<\/p>\n Date:<\/strong> [Date]<\/p>\n Physician\u2019s Signature:<\/strong> (required) [Signature]<\/p>\n Date:<\/strong> [Date]<\/p>\n","protected":false},"author":429,"template":"","meta":{"site-sidebar-layout":"default","site-content-layout":"","ast-site-content-layout":"default","site-content-style":"default","site-sidebar-style":"default","ast-global-header-display":"","ast-banner-title-visibility":"","ast-main-header-display":"","ast-hfb-above-header-display":"","ast-hfb-below-header-display":"","ast-hfb-mobile-header-display":"","site-post-title":"","ast-breadcrumbs-content":"","ast-featured-img":"","footer-sml-layout":"","ast-disable-related-posts":"","theme-transparent-header-meta":"","adv-header-id-meta":"","stick-header-meta":"","header-above-stick-meta":"","header-main-stick-meta":"","header-below-stick-meta":"","astra-migrate-meta-layouts":"default","ast-page-background-enabled":"default","ast-page-background-meta":{"desktop":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"ast-content-background-meta":{"desktop":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"footnotes":""},"class_list":["post-522","savoy_document","type-savoy_document","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/www-lms.stjohns.k12.fl.us\/clinic\/wp-json\/wp\/v2\/savoy_document\/522","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www-lms.stjohns.k12.fl.us\/clinic\/wp-json\/wp\/v2\/savoy_document"}],"about":[{"href":"https:\/\/www-lms.stjohns.k12.fl.us\/clinic\/wp-json\/wp\/v2\/types\/savoy_document"}],"author":[{"embeddable":true,"href":"https:\/\/www-lms.stjohns.k12.fl.us\/clinic\/wp-json\/wp\/v2\/users\/429"}],"version-history":[{"count":0,"href":"https:\/\/www-lms.stjohns.k12.fl.us\/clinic\/wp-json\/wp\/v2\/savoy_document\/522\/revisions"}],"wp:attachment":[{"href":"https:\/\/www-lms.stjohns.k12.fl.us\/clinic\/wp-json\/wp\/v2\/media?parent=522"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}Student Information<\/h2>\n
Nursing Services and Medication\/Treatment Order<\/h2>\n
\n\n
\n \nName of Medication\/Treatment<\/th>\n Amount (Dosage)<\/th>\n Time to be Given<\/th>\n Date to Start<\/th>\n Date to End<\/th>\n Health Condition Requiring Medication<\/th>\n Possible Side Effects<\/th>\n Special Instructions<\/th>\n Physician Ordering Medication<\/th>\n<\/tr>\n<\/thead>\n \n [Medication\/Treatment Name]<\/td>\n [Dosage]<\/td>\n [Time]<\/td>\n [Start Date]<\/td>\n [End Date]<\/td>\n [Health Condition]<\/td>\n [Side Effects]<\/td>\n [Special Instructions]<\/td>\n [Physician Name]<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n Parent\/Guardian Authorization<\/h2>\n
Emergency Medication (Inhaler\/Epinephrine)<\/h2>\n