Administering Medication
Please sign and return this form ONLY if your child currently takes long-term medication! Pupils requiring long-term medication, including aspirin or Tylenol, at school shall be identified by the parents to the principal. He/She shall assume authority for involving designated school personnel in administration of the medication. This does not prohibit the older and reliable student from being given responsibility for him/herself with the approval of the parents and physician. Written statements shall be required of the parents, who shall request and authorize the designated school personnel to give medication. All medication shall be provided to school personnel in a properly labeled, pharmacy provided bottle that indicated the dosage and frequency of administration. If more knowledge is needed by the school authorities to exercise prudent judgment for the safety and protection of the student, permission shall be granted by the parents for the school to contact the physician directly. School personnel should under no circumstances provide aspirin or any other medicine to students without meeting the above criteria.
I hereby give my consent for my child to receive medication from the school staff member as appointed by the school principal. I understand that the school is not responsible in any way for the loss of medication.
Student Name (one form per child):
*
First Name
Last Name
Signature
*
Medication #1 Name:
*
Dosage Amount:
*
Purpose of Medication:
*
Amount Given Per Dose:
*
Frequency Given:
*
Time to Administer Medication:
*
Hour Minutes
AM
PM
AM/PM Option
Medication #2 Name:
Dosage Amount:
Purpose of Medication:
Amount Given Per Dose:
Frequency Given:
Time to Administer Medication
Hour Minutes
AM
PM
AM/PM Option
Medication #3 Name:
Dosage Amount:
Purpose of Medication:
Amount Given Per Dose:
Frequency Given:
Time to Administer Medication
Hour Minutes
AM
PM
AM/PM Option
Preview PDF
Submit
Should be Empty: