Permission to Administer Medicine Authorization Form

Permission to Administer Medicine Authorization Form

Parent/Guardian will provide the school with medication in a prescription bottle or original container if medication is over-the-counter. Eastgate Academy will NOT accept any pills in unlabeled bags, etc. No medication will be given without appropriate packaging/dosing instructions.
Student Full Name (Please Print) First Name*   Last Name*
Grade/Teacher   *
Name of Medication   *
I request and authorize school personnel to give this medication to this student and to contact the physician directly if there are any concerns about the medication or the student's condition. I understand that I have the ultimate responsibility for providing the school with an adequate supply of medication and to inform the school immediately if any information provided on this from changes OR if the administration of the medicine should stop. I agree to hold harmless Eastgate Academy,
Eastgate United Pentecostal Church, and/or any employee, volunteer or representative thereof, for any effects as a result of giving the medication.
Parent/Guardian Full Name (Please Print)   First Name*   Last Name*
Parent/Guardian Signature   Signature*
Date   Date*
Phone   Area Code*   Phone Number*
Email   Email*
The following section is to be filled out by the Physician.
Select*

PrescriptionOTC
Name of Medication
Diagnosis for Medication
Route of Administration
Dose Prescribed
Time Administered
How often Repeated?
Side Effects
Length of Treatment?

Physician's Name   First Name   Last Name
Phone   Area Code   Phone Number
Physician's Signature   Signature
Should be Empty: