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Welcome
Academics
Admissions
Gallery
Extracurricular
Portal Login
Contact
Medication Administration Form
The Parent/Guardian of
Ask that School Staff give the following medication during school hours according to the Health Care Provider's signed instructions on this form
*
The school agrees to administer medication prescribed by a licensed health care provider. It is the parent’s responsibility to furnish the medication on a regular basis. The parent agrees to pick up the expired or unused medication within one week of notification by school staff.
Prescription medications must come in a pharmacy-labeled container.
By signing this document, I give permission for my child’s health care provider to share information about the administration of this medication with school staff delegated to administer the medication.
Parent/Guardian Name
*
Phone
*
(###)
###
####
Parent/Guardian Signature
*
Date
MM
DD
YYYY
Healthcare Provider Authorization to Administer Prescription Medication in School
Child's Name
*
First Name
Last Name
Birthdate
*
MM
DD
YYYY
Medication (name & dosage)
*
To be given at the following times
*
Purpose of Medication
*
Side effects to be reported
*
Additional special instructions
*
Starting Date
*
MM
DD
YYYY
Ending Date
*
MM
DD
YYYY
Signature of Healthcare Provider with Prescriptive Authority
*
License Number#
*
Phone
*
(###)
###
####
Date
*
MM
DD
YYYY
Thank you!