Download IMMACULATA HIGH SCHOOL 240 Mountain Ave. Somerville, NJ

IMMACULATA HIGH SCHOOL
240 Mountain Ave.
Somerville, NJ 08876
(908) 722-0200, Fax (908) 218-7765
Health Office
Dear Parents, Guardians, and Students,
It is the policy of Immaculata High School that no medication is to be kept in the student’s possession or
locker. This includes simple over the counter drugs such as aspirin, Tylenol, vitamins, etc.
All students who require medication for whatever reason must do the following:
1. Present a written consent signed by the parent or legal guardian requesting the administration of
the prescribed medication at school. Verbal consent is not acceptable. It must be written out and
signed.
2. Written orders are to be provided to the school from the private physician, detailing the diagnosis
of type of illness involved in the name of the drug, dosage and time of administration.
3. The medication should be brought to the school in the original container, appropriately labeled
by the pharmacy or physician, with the student’s name. Absolutely no medication will be given
to a student without any of the proper consents and written orders by a physician. There are no
exceptions.
TO BE COMPLETED BY PHYSICIAN
Name of Student _____________________________________________________________________
Diagnosis ___________________________________________________________________________
Name of Medication __________________________________________________________________
Time to be given _____________________________________________________________________
Dosage to be given ____________________________________________________________________
Length of treatment ___________________________________________________________________
Standing order for ____Tylenol 500 mg po PRN q 4 hours or Ibuprofen 400 mg po PRN q 4 hours_____
Name of Physician (Please Print) ________________________________________________________
Signature of Physician Date ____________________________________________________________
Parent Permission _____________________________________________________________________