This order is valid ONLY for the school year (current) ___________________ including the ESY/summer session. PART 1: PARENT/LEGAL GUARDIAN TO COMPLETE Student’s Name: Birthdate: School
This order is valid ONLY for the school year (current) ___________________ including the ESY/summer session. PART 1: PARENT/LEGAL GUARDIAN TO COMPLETE Student’s Name: Birthdate: School: Grade:
Attachment 5 to A.P. 5163 PRINCE GEORGE’S COUNTY PUBLIC SCHOOLS Prescriber’s Medication Order Form Emergency Medication-DIASTAT-For Management of Seizures This order is valid ONLY for school
Attachment 2 to A.P. 5163 PRINCE GEORGE’S COUNTY PUBLIC SCHOOLS Prescriber’s Medication Order Form Prescription and Non-Prescription Medication ONE medication per form This order is valid
Attachment 3 to A.P. 5163 PRINCE GEORGE’S COUNTY PUBLIC SCHOOLS Prescriber’s Medication Order Form Emergency Medication-EPI-PEN THIS IS A LIFE THREATENING EVENT This order is valid ONLY
Mail this form to: Enter ID # below if not shown or if different from above Number of New prescriptions: Number of Refill prescriptions: Please use blue or black ink, capital letters, and fill
Prince George’s County Public Schools Office of Health Services Medication Inventory for Controlled Drugs Name of Student: _________________________________ (DOB: ___________) School: _________
Medication & Physical Examinations Medication Medicacion Physical Examinations Evaluaciones Fisicas Health Forms / Formas de Salud Medicine, including aspirin can not be administered by the school.
This order is valid ONLY for the school year (current) ___________________ including the ESY/summer session. PART 1: PARENT/LEGAL GUARDIAN TO COMPLETE Student’s name: Birthdate: School: Grade:
