REQUEST FOR ADMINISTRATION OF
MEDICATION
2008-2009
NOTE TO PARENTS/GUARDIANS:
School personnel are not pemitted to
give medication of any kind – prescription and/or non-prescription, unless the
parents/guardians request in writing that there is a need for such medication.
I request that my child,
Name (last, first) of Student Birthdate Date
be
given the following medication during school hours to promote optimun health,
and to help maintain maximum school performance:
Name of Medication ______________________ Dosage
strength ________
Reason for medication given _________________________________________
Form of medication to be given is circled below:
Tablet Pill Capsule Liquid Inhalation
Other (specify)
____________________________________________
Dosage (amount to be
given) _________________________________
How often or at what
time(s) _________________________________
Date discontinued
__________________________________________
I agree to hold the school harmless for the proper administration of
medication provided by the parent/guardian, and for adverse drug reactions or
side effects.
I agree to be responsible for maintaining an adequate supply of
medication at the school to meet the child’s needs. Medications must be properly labeled and
stored in the office.
Parent/Guardian Signature ___________________________________________
Phone: (home) ____________ (work)
______________ (cell) ___________
(Additional forms are available in the school
office)