Authorization of Administration of Medicine

AUTHORIZATION OF ADMINISTRATION OF MEDICINE
Please note that the School may contact you in order to confirm your child's absence.
Student Information
Student Name*

First NameLast Name
Grade*
Parent / Guardian Information
Parent / Guardian Name*

First NameLast Name
Email Address*
example@example.com
Phone Number*
Medication Information
Name of Medication*
Amount*
Time*
Name of Medication
Amount
Time
Name of Medication
Amount
Time
List all possible reactions to medication of which Legacy staff should be aware of
Legacy Christian Academy will only administer prescribed medication that is in the original prescription container with the prescription label on the front detailing authorized dosage instructions from the doctor.Additionally, any non-prescription or over-the-counter medications will not be administered unless the school is provided with a Ziploc bag containing the medication and a signed doctor’s authorization note specifically detailing dosage information.
By checking this box, I release Legacy Christian Academy from all liability for reactions which my child may endure from this medication
By checking this box, I request that the staff of Legacy Christian Academy administer the following prescription medication in the following dosages and times to my child.
Signature*

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Legacy Christian Academy

27680 Dickason Drive
Valencia, CA 91355
Phone: 661.257.7377
Should be Empty:

AUTHORIZATION OF ADMINISTRATION OF MEDICINE