Rev. 06.01.15 Copy: School File NOTE: This plan will be shared with all appropriate school district staff
Huron Valley Schools – Plan of Care (POC)
Administering Medicine(s) to Students
Bus Route _______________
Student Name: ____________________________________ School: ________________________ Grade: _____
Dear Parents and Physician:
It is the policy of , in compliance with Michigan Compiled Laws Section 380.1178, to
have written authorization for a student to take prescribed medication during the school day. This information will
be handled in a confidential manner. Authorization is valid for one school year only.
MEDICATION NEEDS TO BE IN ITS ORIGINAL CONTAINER
Student Date of Birth: ______________
Check one (1):
Authorization is hereby granted for school personnel to administer medication to the above named student,
in accordance with the following physician’s directive
I request that the above named student be allowed to carry/self-administer medication at the school according to
school policy in pursuant to the physician’s approval.
1. Name of Medication: _____________________________________________ Dosage: ___________________
Reason for medication: ________________________________________________________________________
To be given at: _________________________________ (time/hour)
Date Range: ________________________________ to ____________________________________
Comments regarding medication (adverse reactions, precautions, special instructions, etc.):
This student is both capable and responsible for carrying this medication Yes No
This student may carry this medication Yes No
2. Name of Medication: _____________________________________________ Dosage: ____________________
Reason for medication: ________________________________________________________________________
To be given at: _________________________________ (time/hour)
Date Range: ________________________________ to ____________________________________
Comments regarding medication (adverse reactions, precautions, special instructions, etc.):
This student is both capable and responsible for carrying this medication Yes No
This student may carry this medication Yes No
In case of emergency, contact: ______________________________________Phone_______________________
_________________________________ / _________ ____________________________________ /_________
PARENT SIGNATURE DATE PHYSICIAN SIGNATURE DATE
Physician Name _________________________________
Physician Address _______________________________
Physician Phone ________________________________
