ADMINISTRATION OF MEDICATION FORM
We attempt to
discourage the administration of medication during school hours; and, request,
whenever possible, that medication be administered at home. We realize that this is not always possible;
and will cooperate in the administering of medication when necessary.
PERMISSION TO
ADMINISTER MEDICATION
I
give permission for _____________________________ to receive
the medication prescribed by_____________________________________________ .
Student
Name Physician's
Name
Name
of Medication____________________________________ Date/s to be given______________
Time
to be given_______________________________________ Dosage______________________
Reason for Medication_________________________________________________________________
The
medication should be in an appropriate container; labeled with the student’s
name, name of
medication, amount and time to be given, and duration. PLEASE DO NOT SEND MEDICATION IN BAGGIES,
KLEENEX, OR ALUMINUM FOIL.
________________________________________________ _________________________________
Parent/Guardian
Signature Daytime Phone Number
________________________________________________
Date
I
request that the appropriate dose(s) of the above medication be sent on field
trips to be given by my child's teacher or designated adult.
________________________________________________ _________________________________
Parent/Guardian
Signature Date