Student's Full Name: _____________________     Date of Birth: _________________                 

School: ___________________________________________________________

School medications and health services are administered following these guidelines:

• Parent has provided a signed, dated authorization to administer prescription medication and/or provide the health service.  Electronic signatures meet the requirement of written signatures.

• The prescribed medication is in the original, labeled container as dispensed. 

• The prescription medication label contains the student’s name, name of the medication, the medication dosage, time(s) to administer, route to administer and date.

• Authorization is renewed annually and as soon as practical when the parent notifies the school that changes are necessary.

 

___________________        _______        _______    ____________

Prescribed Medication          Dosage           Route         Time at School

 

Special Health Services and instructions, if indicted:

____________________________________________________________________________

____________________________________________________________________________ 

Administration instructions

 

____________________________________________________________________________

____________________________________________________________________________  

Special Directives, Signs to Observe and Side Effects

 

_____/_____/_____ 

Discontinue/Re-Evaluate/Follow-up Date

 

 

__________________________                _____/_____/_____ 

Prescriber’s Signature                                     Date

And credentials (when indicated for health service delivery)

 

 

______________________________                ____________ 

Parent's/Guardian Signature                                 Date

 

 

______________________________                ____________

Parent/Guardian address                                    Home/Cell Phone

 

 

______________________________                _____________

Additional Information                                          Business Phone

 

Cross References:

    603.3        Special Education

    607.2        Student Health Services

    607.2R1    Student Health Services - Regulation

 

Approve:  2/10/1997        Reviewed: 08/14/2023        Revised:  08/14/2023

 

Code No. 507.2E3 

TIPTON COMMUNITY SCHOOL DISTRICT

PARENTAL AUTHORIZATION AND RELEASE FORM FOR INDEPENDENT 

SELF CARRY AND ADMINISTRATION OF PRESCRIBED MEDICATION OR

INDEPENDENT DELIVERY OF HEALTH SERVICES BY THE STUDENT 

 

_________________________________            ___/___/___ _________________ ___/___/___

Student's Name (Last), (First), (Middle)                Birthday         School                          Date 

 

I request the above-named student (Parent/Guardian initial all that apply)

 

 ______ Carry and complete co-administration of prescribed medication, when competency has been demonstrated to licensed health personnel working under the auspices of the school. In accordance with applicable laws, students with asthma, airway constricting diseases, respiratory distress or students at risk of anaphylaxis who use epinephrine auto-injectors may self-administer their medication upon the written approval of the student’s parents and prescribing licensed health care professional regardless of competency. The information provided by the parent for medication administration is confidential as provided by the Family Education Rights and Privacy Act (FERPA) and any other applicable laws. I agree to provide safe delivery of the medication to and from school and to pick up remaining medication at the end of the school year or when medication is expired. If the students abuses the self-administration policy, the ability to self-administer may be withdrawn by the school or discipline may be imposed, after notification is provided to the student’s parent. 

 

____________________________________________________________________________Prescribed Medication                Dosage                   Route                    Time at School 

 

______ Co-administer, participate in planning, management and implementation of special health services at school and school activities after demonstration of proficiency to licensed health personnel working under the auspices of the school. The information provided by the parent for health service delivery is confidential as provided by the Family Education Rights and Privacy Act (FERPA) and any other applicable laws. I agree to coordinate and work with school personnel and the prescriber (if indicated) when questions arise. I agree to provide safe delivery of the student’s equipment necessary for health service delivery to and from school and to pick up remaining equipment at the end of the school year. 

 

Special Health Services Delivery: 

 

___________________________________________________________________________

 

___________________________________________________________________________

 

Procedures for abandoned medication disposal shall be in accordance with applicable laws. 

 

____________________________                  ___________________

Prescriber’s Signature                                       Date 

and credentials (when indicated for health service delivery) 

 

 ____________________________                  ___________________ 

Parent/Guardian Signature                                Date

 

__________________________                       _____________________

Parent/Guardian address                                   Home phone

 

Cross Reference:

    603.3      Special Education

    607.2    Student Health Services

    607.2R1  Student Health Services - Regulation

 

Approved: 08/14/2023         Reviewed:  _____________   Revised:  _______________

 

Code No. 507.2E4

Page 1 of 2

TIPTON COMMUNITY SCHOOL DISTRICT

PARENTAL AUTHORIZATION AND RELEASE FORM FOR THE ADMINISTRATION

OF VOLUNTARY SCHOOL STOCK OF OVER-THE-COUNTER MEDICATION TO STUDENTS

 

___________________________       ___/___/___   _________________  ___/___/___

Student's Name (Last), (First), (Middle) Birthday         School                         Date

 

The district supplies the following nonprescription, over-the-counter medications that are listed below. Generic brands may be substituted, (select all that apply):

• Acetaminophen administered per manufacturer label

• Throat Lozenges administered per manufacturer label

• Other: ____________________ administered per manufacturer label (Please Specify)

• Other: ____________________ administered per manufacturer label (Please Specify)

• Other:____________________ administered per manufacturer label (Please Specify)

• Other:____________________ administered per manufacturer label (Please Specify)

 

Voluntary school stock of nonprescription, over-the-counter medications are

administered following these guidelines:

• Parent has provided a signed, dated annual authorization to administer of the

nonprescription, over-the-counter medication(s) listed according to the manufacturer instructions. Electronic signature meets the requirement of written signature.

• The nonprescription, over-the-counter medication is in the original, labeled container and dispensed per the manufacturing label.

• All other nonprescription, over-the-counter medication not listed will require a written parent authorization and supply for the over-the counter medication.

• Supplements are not nonprescription, over-the-counter medications approved by the Federal Drug Administration and are NOT applicable.

• Nonprescription, over-the-counter medications approved by the Federal Drug

Administration that require emergency medical service (EMS) notification after

administration are NOT applicable.

• Persons administering nonprescription, over-the-counter medication include licensed health personnel working under the auspices of the school and individuals, whom licensed health personnel have delegated the administration of medication with valid certification who have successfully completed a medication administration course approved by the department and annual medication administration procedural skills check.

 

O Districts stocking the administration of a voluntary stock of nonprescription, over-the-counter medications, collaborate with licensed health personnel to develop and adopt a protocol shared with the parent to define at a minimum:

• when to contact the parent when a nonprescription medication, over the counter medication is administered
• documentation of the administration of the nonprescription, over-the-counter medication and parent contact;
• a limit to the administration of a school’s stock nonprescription, over-the-counter medications that would require a prescriber signature for further administration of a school’s nonprescription, over-the-counter medications for the remaining school year;
• the development of an individual health plan for ongoing medication administration or health service delivery at school.

 

I request that the above-named student receive the voluntary stock nonprescription, over-the-counter medications supplied by the school in accordance with the district guidelines and protocol.

 

 

__________________________________________ _________________________

Parent Signature                                                           Date

 

 

__________________________________________ _________________________

Parent/Guardian Address                                              Home Phone

 

 

 

Approved:  08/14/2023               Reviewed:  ______________                 Revised:  ____________

To implement the Wellness Policy, the following district specific goals have been established: 

Goal 1 – Nutrition Education and Promotion:  Schools will provide nutrition education and engage in nutrition promotion that help students develop lifelong healthy eating behaviors. The goal(s) for addressing nutrition education and nutrition promotion include the following

• Provide students with the knowledge and skills necessary to promote and protect their health

• Promote fruits, vegetables, whole-grain products, low-fat and fat-free dairy products, and healthy foods;

• Link with school meal programs, cafeteria nutrition promotion activities, school gardens, Farm to School programs, other school foods, and nutrition-related community services;

• Implement evidence-based healthy food promotion techniques through the school meal programs using Smarter Lunchroom techniques; 

Goal 2 – Physical Activity: Schools will provide students and staff with age and grade appropriate opportunities to engage in physical activity that meet federal and state guidelines, including the Iowa Healthy Kids Act. The goal(s) for addressing physical activity include the following:

• Develop a comprehensive, school-based physical activity program (CSPAP), that includes the following components: 

  • Physical education, recess;

• Classroom-based physical activity; 

• Promote the benefits of a physically active lifestyle and help students develop skills to engage in lifelong healthy habits; 

• Encourage classroom teachers to provide short physical activity breaks (3-5 minutes), as appropriate;

• Ensure physical activity is not used for or withheld as a punishment;

• Afford elementary students with recess according to the following: 

• At least 20 minutes a day; 

• Outdoors as weather and time permits; 

• Encourages moderate to vigorous physical activity; and

Goal 3 – Other School-Based Activities that Promote Student Wellness: Schools will support student, staff, and parents’ efforts to maintain a healthy lifestyle, as appropriate. The goal(s) for addressing other school-based activities that promote student wellness include the following:

• Provide school staff a list of alternative ways to reward children. Foods and beverages will not be used as a reward, or withheld as punishment; 

• Develop a plan to promote staff health and wellness;

• Share information about the nutritional content of meals with parents and students; 

• Support the consumption of breakfast at school by implementing alternative breakfast options to the extent possible (e.g., grab n’ go, breakfast in the classroom, breakfast after 1st period, etc.);

• Permit students to bring and carry water bottles filled with water throughout the day; 

• Make drinking water available where school meals are served during mealtimes; 

• Encourage fundraising efforts held outside school hours to sell only non-food items, promote physical activity, or include foods and beverages that meet or exceed the Smart Snacks nutrition standards; 

• Strive to provide students with at least 10 minutes to eat after sitting down for breakfast and 20 minutes after sitting down for lunch; 

Public Involvement: There is a process for permitting parents, students, representatives of the school food authority, teachers of physical education, school health professionals, the school board, administrators and the public to participate in the development, implementation, and periodic review and update of the policy. 

• The superintendent or superintendent’s designee invites suggestions or comments concerning the development, implementation, and improvement of the school wellness policy. As such, interested persons are encouraged to contact the superintendent or superintendent’s designee.

NOTE: School districts are required by federal law to have at least one specific wellness goal in each of the goal areas identified above. These goal areas include the following: nutrition promotion and education, physical activity, and other school-based activities that promote student wellness. Options have been provided, but districts must remember the sample policy and sample regulation cannot be adopted in the current format. School boards and administration must make a choice for all text in italicized brackets. 

NOTE: The Iowa Department of Education has tools and resources available to help districts with progress reports and other aspects of policy implementation and review. Please visit the “School Wellness Policy” section of the Iowa Department of Education’s website, located at: https://www.educateiowa.gov/pk-12/nutrition-programs/school-wellness. 

Cross Reference:

      504.06         Student Activity Program

Approved:  1/9/2018                           Reviewed:    05/13/2024                     Revised:  05/13/2024