Parental Permission Forms

Policy Date: 01/07/2026

CSD FILE: JLCD

CANDIA SCHOOL DISTRICT
ADMINISTERING MEDICATION TO STUDENTS

The Superintendent shall be responsible for establishing specific procedures to control medications
administered in schools. Such procedures are found in Appendix JLCD-R.

Prescribed medication should not be taken during the school day, if at all possible. Medication is to be
administered by the school nurse, principal or other designee. Medication will be administered in school
only after receiving and filing in the student’s health record the following:

1. A written statement from the licensed prescriber detailing the method of taking the
medication, dosage, and the time schedule of the medication.

2. A written authorization from the parent/guardian indicating the desire that the school
assist the student in taking the prescribed medication.

All medication should be delivered to appropriate school personnel by the parent/guardian. All
prescription medication must be delivered and contained in its original pharmacy container. The school
nurse is directed to keep such medications in a locked cabinet or refrigerator. No more than a 30-day
supply will be kept and maintained by the school. The school nurse will contact the parent/guardian
regarding any unused medication. Such medication shall be picked up by parent/guardian within ten
days after its use is discontinued. If the parent/guardian does not pick up the medication within ten
days, the school nurse may dispose of the unused medication and record as such in the student’s health
record file.

The school nurse is responsible for keeping accurate records regarding the administration of medication
to students.

Students may possess and self-administer an epinephrine auto-injector or nasal spray if the student
suffers from potentially life-threatening allergies. Both the student’s parent/guardian and physician
must authorize such self-possession and self-administration. If a student finds it necessary to use
his/her auto-injector or nasal spray, s/he shall immediately report to nearest supervising adult. The
school nurse or building principal may maintain at least one epinephrine auto-injector or nasal spray,
provided by the student, in the nurse’s office or other suitable location. Additionally, students may
possess and self-administer a metered dose inhaler or a dry powder inhaler to alleviate or prevent
asthmatic symptoms, auto-injectors or nasal spray for severe allergic reactions, and other injectable
medications necessary to treat life-threatening allergies. Both the student’s parent/guardian and
physician must authorize such self-possession and self-administration.

The district will maintain a supply of epinephrine for use in an allergic emergency when a nurse is
employed or contracted by the district. The nurse shall determine the quantity and type of medication
the school should maintain.

If epinephrine is used, the school nurse shall order a replacement within 5 business days. (HB677).

Students shall not share any prescription or over-the counter medication with another student. Notice
of this prohibition will be provided in student handbooks. Students acting in violation of this prohibition
will be subject to discipline consistent with applicable Board policies.

This policy shall extend to any school-sponsored activity, event, or program.

In addition to the provisions set forth herein, the school nurse and principal are responsible for ensuring
the provisions of Ed. 311.02, Medication During the School Day, are followed.

The school nurse or other designated personnel may administer other medications to students in
emergency situations, provided such personnel has all training as is required by law. Such
medication may also be administered in emergency situations if a student’s medical action plan has
been filed and updated with the school district to the extent required by law. The district will
maintain all necessary records relative to the emergency administration of medication and will file all
such reports as may be required.

Legal References:
RSA 200:40-b, Glucagon Injections
RSA 200:42, Possession and Use of Epinephrine Auto-Injectors Permitted
RSA 200:43, Use of Epinephrine Auto-Injector
RSA 200:44, Availability of Epinephrine Auto-Injector
RSA 200:44-a, Anaphylaxis Training Required
RSA 200:45, Student Use of Epinephrine Auto-Injectors – Immunity
RSA 200:46, Possession and Self-Administration of Asthma Inhalers Permitted
RSA 200:47, Use of Asthma Medications by Students – Immunity
RSA 200:54, Supply of Bronchodilators, Spacers or Nebulizers
RSA 200:55, Administration of Bronchodilator, Space or Nebulizer
N.H. Code of Administrative Rules – Section Ed. 306.12(b)(2), Special Physical Health
Needs of Students
N.H. Code of Administrative Rules – Section Ed. 311.02(d); Medication During School Day

Appendix JLCD-R

Adopted: June 11, 1985
Adopted: January 3, 2002
Adopted: June 2, 2005
Revised: February 5, 2009, March 9, 2017, January 7, 2026

CSD File: JLCD-R
HENRY W. MOORE SCHOOL
MEDICATION ADMINISTRATION FORM

PARENT/GUARDIAN PLEASE FILL OUT:

Name of Student _________________________________________________ DOB_______________________

Teacher________________________________________________________ GRADE______________________

Name of Medication___________________________________________________________________________

Dose to be given_____________________________________________________________________________

Time and frequency of medication to be given______________________________________________________

Reason for medication_________________________________________________________________________

Prescribing Physician__________________________________________________________________________

Beginning__________________________________to (list dates) ______________________________________

The medication MUST be delivered to the School Nurse or Principal’s Office by a parent or responsible adult.
All medication is to be in a container properly labeled with student’s name, physician’s name, name and dosage of medication.

I authorize the school to assist my child in taking the above medication. I will not hold liable any member of the school staff or an individual of official capacity who is directed by myself (the parent/guardian) and the school administrator to assist my child in taking said medication.

_________________________________________________________ ________________________________
Parent/Guardian signature Date

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PHYSICIAN PLEASE FILL OUT:

Name of Student ________________________________________Diagnosis___________________________

Medication/Dosage_______________________________________Time schedule_______________________

Medication to be taken beginning________________________to (list dates)____________________________

Licensed Provider Signature_________________________________Date______________________________

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FOR METERED DOSE INHALERS OR EPIPEN MEDICATION ONLY:

IF YOU REQUEST THAT YOUR CHILD CARRY HIS/HER INHALER OR EPIPEN WITH THEM, PLEASE HAVE THE FOLLOWING COMPLETED.
PHYSICIAN PLEASE FILL OUT:

I have instructed__________________________________in the proper way to use______________________________________

It is my professional opinion that he/she should be allowed to carry and use that medication by his/herself without supervision.
YES NO

Licensed provider signature______________________________________________Date___________________________________

PARENT/GUARDIAN:

I agree with the above physician’s statement that my child has been instructed in the proper way to use this medication and should be allowed to carry and use that medication by him/herself without supervision. I give my child permission to do so.
YES NO

IMMEDIATELY AFTER USING THE EPIPEN OR INHALER, DURING THE SCHOOL DAY, THE STUDENT MUST REPORT TO THE URSE OR OFFICE FOR APPROPRIATE FOLLOW-UP CARE.

Parent/Guardian signature____________________________________Date_____________________________