Skip to main content
Mineral County Schools 36 Baker Place, Keyser, WV 26726            Phone: 304-788-4200            Fax: 304-788-4204

Physician Medicine Administration Form

Physician Medicine Administration Form

One Baker Place

Nancy Starcher, RN 788-4200

Trina Melody, RN 788-4213

Sharon Clark, RN 788-4216

Jennifer Cole, RN 726-4339 Roberta Jones, RN 788-4216

Keyser, West Virginia 26726


Michael D. Burke, Director

Rob Woy, Assistant


Dear Parent:

State guidelines require the school to have a completed “Medication Form” for each child who takes any medication at school. This must be completed before any medication will be administered. If any changes occur in medication or dosage, a new form must be completed. Again, no medication will be given without this form completed and submitted to the school nurse.

Please have your physician complete the back of this form completely. After you have signed the parent’s signature line, please return it to school.

Thank you,

Mineral County School Nurse

Medication noted on emergency medical form:______________________________________

(See Back)

Student_______________________________ School/Grade________________________
Birthdate______________________________ Allergies____________________________

This is to be completed entirely before any medication will be administered. The physician must complete and sign the form. If any changes occur in the medication or dosage, a new form must be completed. Only one medication per form please.



Name of Medication____________________________________________________________


Frequency of Administration____________________________________________________

Route of Administration________________________________________________________

Intended effect of Medication____________________________________________________

Comments/Side Effects: ________________________________________________________ ________________________________________________________________________


May student self administer medication? _____ Yes _____ No

Student may self administer the following medication (circle): Epipen Inhaler Insulin

Physician’s Name______________________________________________________________

Physician’s Signature___________________________________________________________

Date_______________________________ Phone Number_______________________

I hereby give my permission for ____________________________________________ to take _____________ ____________________________________ at school as ordered by the physician. I understand that it is my responsibility to provide this medication. I further understand that any school nurse or employee who administers this drug to my child, in accordance with written instructions from the physician, shall not be liable for damages as a result of an adverse drug reaction suffered by my child due to the administration of the drug.

I understand that the medication must be brought to school in the original container appropriately labeled.

________________________________________________ __________________________________

Signature of Parent Date

Some links may direct to 3rd party websites which may not meet accessibility standards.
MINERAL COUNTY SCHOOLS: 36 Baker Place, Keyser, WV. 26726      |      Phone: 304-788-4200      |      Fax: 304-788-4204
© 2020. Mineral County Schools. All Rights Reserved.
View text-based website