MEDICATION
ADMINISTRATION
FORMS

Contact: 
DMS School Nurse - Justine Powell
schoolnurse@durangomontessori.com

Medication Administration​​*All forms need to be completed by parent, the child's health care provider, and the DMS school nurse 

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If DMS staff is responsible for administering routine or as needed medication to your child. (inhalers, epi-pens, over-the-counter medicines, antibiotic courses, daily scheduled medicines, etc). ​Staff members administering medications have completed state sanctioned Medication Administration Training and reviewed individual student needs with DMS’ school nurse.

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Self Carry Form *All forms need to be completed by parent, the child's health care provider, and the DMS school nurse 

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If your child is responsible for their own medication administration this form needs to be completed to give permission for the student to administer medication on their own. 

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Care Plans*All forms need to be completed by parent, the child's health care provider, and the DMS school nurse 

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If a student has been diagnosed with asthma, allergy/anaphylaxis, seizures, or diabetes, a specialized care plan must be completed by the student’s provider and parent. 

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Asthma

Allergy/Anaphylaxis

Seizures

Diabetes

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Procedure for Submitting Medication

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1. Medication is in the original container

2. Container is labeled with the student’s name

3. Dosage instructions are included

4. Prescription medication bottles must have pharmacy label containing:

   1. Medication name

   2. Time and route the medicine is to be given

   3. Medication stop date or date of expiration

   4. Prescribing provider’s name and phone number

   5. Pharmacy name and phone number

5. Over-the-counter medication bottles must be new/unopened with a label containing:

   1. Medication name

   2. Expiration date

   3. Directions for safe use

   4. Ingredient list

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DMS School Nurse: Justine Powell schoolnurse@durangomontessori.com