1. Request by Student to Possess
  2. And Self-Administer Prescription Medication

Haysville USD 261
1745 West Grand
Haysville, KS 67060
(316) 554-2200
Fax (316) 554-2230
Date
Name:
Address:
City, State, and Zip:
This letter is intended to clarify your appeal of an official Board of Education policy as per allowing a student to keep on their person
prescription medication. The Board has made an exception to their policy in the case of ______________________ and your parental
request to allow him/her to carry a prescription.
For this exception to go into affect, it will be necessary for you to comply with the following within thirty (30) days of receipt of this
letter. To:
1) A Request by Student to Possess and Self-Administer Prescription Medication Form must be signed and on file in the
DS’ .
You and your physician must sign form. Form is enclosed in this letter for you convenience.
2) The medication must be in a protective manner that it cannot be accidentally left or forgotten. Should the medication
ever be
S’ ,
B yy .
3) The parent agrees that the school may contact the physician prescribing the medication at the discretion of the school
district.
Please note that the signing by the parent of the Medication form indicates agreement and acceptance to all items above.
Please be advised that the Board of Education certainly does not desire to make this a difficult situation for your family. The above
steps are absolutely necessary, however, to afford the school district some protection from liable and potentially devastating financial
loss due to possible litigation.
Thank you for your understanding,
Respectfully yours,
Dr. John Burke
Superintendent of Schools

Request by Student to Possess

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And Self-Administer Prescription Medication
Dear Physician:
The below student and their legal guardian(s) have requested permission to carry on their person and
self-administer a prescription drug prescribed by your office. This is in violation USD 261 district
policy. To receive a waiver to said policy, it is necessary for this form to be signed by the prescribing
physician. The district apologizes for any inconvenience this may cause you and we thank you for
your time.
Name of Student______________________________ Date of Birth__________
Address__________________________________________________________
School_______________________Grade_______Teacher_________________
Medication____________________________Dosage_____________________
Date Medication Started_____________________________________________
Anticipated Number of Days to be administered at School__________________
**It is absolutely necessary for the health and well being of this student that the above medication be
carried on their person at all time during the school day. Further, absence of this medication when
needed for even an extremely short period of time may cause very serious physical damage and/or
. A ’ y, Iy
carry and self-administer the drug(s) listed.
___________________________________ ___________________________
Signature of Physician
Date
I herby give my permission for __________________________________to take the aforementioned
prescription at school. I understand that is my responsibility to furnish this medication. I further both
request and give my permission that this student be allowed to carry said medication on their person
and to self-administer such.
I hereby release Unified School District 261, the Board of Education, and all it agents, servants, and
y y y
-administration of the listed
prescriptions and/or drugs.
_________________________________
_____________________
Parent and/or Legal Guardian
Date
_________________________________
Witness

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