Shalom SBC.Med Consent parent portion.2023-24 SY.ENG

Shalom School-Based Clinic Consent to Administer a Medication

(PARENT/GUARDIAN SECTION)
Last Name:*
First Name:*
Date of Birth:*

MonthDayYear
School*
Medication Name and Dosage:
Instructions, including TIME to give medication:
Med Type:

PrescriptionControlledOver the counter
For late/delayed arrival, please:

Give medication when arrives to clinicContact me before giving medicationHold medication if arrives after
Initial*

Clear
For early/alternate dismissal, please:

Hold the medicationContact me before giving medicationGive medication at
Initial*

Clear
I authorize clinic staff to administer the medication as described here. Medication(s) be stored in secure location in clinic.
Initial*

Clear
My authorization will be in effect until a termination or change in medication is submitted in writing or at the end of the school year.
Initial*

Clear
I understand all medications will be counted in with SBC staff and an adult school staff witness. All medications must be labeled. Prescription medications must have a valid pharmacy label. Medication(s) may only be labeled for one student.
Initial*

Clear
Any medication left in the clinic past the last day of school will be wasted/destroyed per Indiana state law.
Initial*

Clear
I give permission for my child to transport non-controlled medications to/from school in labeled container.
Initial*

Clear
I agree it is my responsibility to notify clinic staff of any changes immediately and in writing. This is to be done electronically through my child's patient portal.
Initial*

Clear
Please notify me when my child has _______ doses left of their medication to allow adequate time to get a refill. Please do this by:
Text
Email
Call
Initial*

Clear
Signature:*

Clear
Date:*

MonthDayYear
Name*
Daytime #:*
Relationship to Student:*
Email:
ShalomHCC.SBCMedConsent.ENG.2023-24 School Year
Should be Empty: