MEDICATION ADMINISTRATION RELEASE FORM

                                                                                    Date______________________

I request that you give medication to my child during the school day in accordance with Board policy printed below.  I will not hold the school staff responsible for any undesired reaction which may occur from the medication.

I agree to pay for ambulance service if used to transport my child from school to the doctor or hospital should he/she have a reaction to the medication.

                                                                Parent Signature______________________

Student's Name_________________________            Class________________

                                                                                                Dosage:  _________mg, tsp., etc.

Name of Medication________________________        # of tabs  _________

Reason for Prescription________________________________________________________

Choose time to be given: ______a.m.  _____ p.m.     [  ]  before lunch      [  ]  after lunch

                                                                                            [  ]  as needed

In case of emergency call ___________________  Phone_________________

Hospital to be called  _______________________ Phone_________________

Doctor to be called  ________________________  Phone_________________

           Clinic Name  ________________________

MEDICATION PROCEDURE

     GUIDELINES

1.  The medication must be in the current, original container with your child's

     name on the prescription.

2.  No medication to be given three (3) times daily or less will be administered at  

     school.

3.  The consent form must be signed before any medication will be given at

      school.     

HANDWRITTEN NOTES ARE NOT ACCEPTABLE.