Medication Administration Form

Medication Administration Form
Any student needing any form of medication at school must have this completed form on file in the school office before any medications will be administered.

Please print the following information:
Student Name:*
Grade*
Grade:
If kindergarten then put grade 0
Medication(s) Information

For each medication please fill in the following
Medication 1
Name of Medication
YesNo
Time(s) of Day to Administer
Dosage Amount
What Date should Administration End?*
Medication 2
Parent/Guardian Signature:*

Clear
Name of Medication
YesNo
Time(s) of Day to Administer
Dosage Amount
What Date should Administration End?*
Medication 3
Name of Medication
YesNo
Name of Medication
Time(s) of Day to Administer
Dosage Amount
What Date should Administration End?*
Medication 4
Name of Medication
YesNo
Name of Medication
Time(s) of Day to Administer
Dosage Amount
What Date should Administration End?*
* Indicate whether the medications are for an on-going need or for a limited time (e.g., 10 days, etc

NOTE: Only original and fully labeled medication containers are acceptable.

I grant permission for qualified North Lakes Academy staff members to administer the medication(s) as described above, and I understand it is my responsibility to resubmit this form any time there are medication changes.
Date:*

MonthDayYear
Date
North Lakes Academy Public Charter School prohibits discrimination based on race, color. region, sex, ethnicity, national origin, age, disability, pregnancy and childbirth, or marital status.
Should be Empty:

Medication Administration Form

Medication(s) Information

Medication 1

Medication 2

Medication 3

Medication 4