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    Niagara Catholic District School Board

    ADMINISTRATION OF MEDICATION

    (When no Individual Student Plan of Care is required)

     
    Personal information on this form is being collected under the authority of the Education Act, in accordance with the Municipal Freedom of Information and Protection of Privacy Act (MFIPPA) and the Personal Health Information Protection Act (PHIPA). The purpose of collection is to identify protocols to follow in the event a student experiences symptoms pertaining to a prevalent medical condition. Questions about this collection should be directed to the Superintendent of Education, Student Support, Niagara Catholic District School Board, 427 Rice Road, Welland, ON L3C 7C1, (905) 735-0240.
    STUDENT PROFILE and INFORMATION
    SCHOOL YEAR
    to
         
    Insert current student photo
    		Student Name  
      First Name
    Last Name
    		 
           
     Date of Birth
    Age
    		 
      
    (MM/DD/YYYY)
    		 
           
      O.E.N.
    Grade
    		 
            
     School  
         
     Teacher(s)  
         
         
        
    PARENT(S)/GUARDIAN(S) & EMERGENCY CONTACT INFORMATION
    Name
    Relationship
    Phone
        
    1.
    		     
          
    2.
    		     
          
    3.
    		     
          
    4.
    		     
          

    PRE-AUTHORIZATION and CONSENT
    ☐   I/We request, give permission and authorize the principal/designate to administer the noted medication, during school hours.

    ☐   I/We understand that it is my/our responsibility to provide the medication in its original pharmaceutical container and the original

    dispensed quantity of medication supplied by the pharmacist, which is clearly labeled indicating my child’s name and administration

    instructions. 

    ☐   I/We understand that it is my/our responsibility to ensure that the school has a supply of medication on hand at any given time. The

    principal/designate will return any remaining medication at the end of the school year.

    ☐   I/We consent to use, share and disclose personal Information related to my child.  Complete the NCDSB Consent to Use, Share and

           Disclose Personal Information Form .

    ☐   I/We give consent to share my child’s photograph on paper notices (binders) or electronic format(s).

    ☐  I acknowledge that I am aware and understand my child’s medical condition and the risks associated with its care and emergency

    treatment, and that the Niagara Catholic District School Board and its staff and volunteers are acting in their role as educators and not

    health care professionals.
    AUTHORIZATION and SIGNATURES
    Parent/Guardian Name (Print) Signature Date
    Parent/Guardian Name (Print) Signature Date
    Student Name, if older than 18 (Print) Signature Date
    Principal/Designate (Print) Signature Date  

    Signatures of the parent/guardian, principal, and physician/medical professional signify agreement regarding the procedures and consent to administer the Medication prescribed by the Physician/Medical Professional, that must be administered during the school hours and consent for pertinent medical information concerning the student to be released as required in accordance with the Municipal Freedom of Information and Protection of Privacy Act.





    alt Niagara Catholic District School Board

    ADMINISTRATION OF MEDICATION

    (When no Individual Student Plan of Care is required)

     
    Personal information on this form is being collected under the authority of the Education Act, in accordance with the Municipal Freedom of Information and Protection of Privacy Act (MFIPPA) and the Personal Heath Information Protection Act (PHIPA). The purpose of collection is to identify protocols to follow in the event a student experiences a medical emergency. Questions about this collection should be directed to the Superintendent of Education, Student Support, Niagara Catholic District School Board, 427 Rice Road, Welland, ON L3C 7C1, (905) 735-0240.

     
    Student Name
    D.O.B.

    (MM/DD/YYYY)
    Complete one form for each medication, if medication is administered, by staff, during the school day
    TO BE COMPLETED BY PHYSICIAN/MEDICAL PROFESSIONAL FOR MEDICATION REQUIRED DURING SCHOOL HOURS
    Medical Condition/ Diagnosis requiring medication
    Name of medication

     
     

    Dosage

     
    Specific Time(s) of day Medication is to be Administered:
    Additional instructions

    (e.g.. storage)
     

    Route of administration

     
     

    Duration of Doctor’s orders     		 

    ☐ Medication is ongoing or              		 

    ☐ Start Date:     		 

    ☐ End Date:
       
     

    Possible side effects

     
    Student can self-administer ☐ YES ☐ NO
    Student will self-carry medication ☐ YES ☐ NO
    PHYSICIAN/MEDICAL PROFESSIONAL INFORMATION and AUTHORIZATION
    Physician/Medical Professional name, address, phone (Stamp accepted)

     

     

     

     

     

     

     
    ☐ I confirm that I have prescribed the above medication(s) that must be administered during the school hours as prescribed.
     

     

     

     

     

     

           		    
     

     

     

     

           		   
    Physician/Medical Professional Signature Date  

    Signatures of the parent/guardian, principal, and physician/medical professional signify agreement regarding the procedures and consent to administer the Medication prescribed by the Physician/Medical Professional, that must be administered during the school hours and consent for pertinent medical information concerning the student to be released as required in accordance with the Municipal Freedom of Information and Protection of Privacy Act.

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