2025-26 Prescription Medicine Authorization

1
Student name* This field is required.
First Name
Last Name
2
2025-26 Grade* This field is required.
Nitzanim
Ilanot
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
3
It is highly recommended that no prescription medication be dispensed at school. If possible, please give your child the necessary dose of prescription medicine before or after school and/or at bedtime.

If your student must have medication during school hours, the parent or guardian needs to complete the form below and submit to the school office. Additionally, if your child requires medication for emergency use (Epi Pen, Albuterol...etc.), please send an emergency action plan from your child's doctor to Donna Baer at dbaer@jcdsri.com.
4
Does your child have any food allergies?* This field is required.
Yes
No
5
Does your child have allergies to ANY medication?* This field is required.
Yes
No
6
If your child suffers from allergies of any kind, please list them here, and describe your child's reactions in detail:
7
If your child requires accommodations in the classroom (i.e. eliminating certain allergens from the space), please indicate that below and submit documentation of this protocol from your child's allergist/physician to Donna Baer (dbaer@jcdsri.com) as soon as possible.
8
My child requires that the following allergen(s) be eliminated from the classroom as per physician's direction:
Allergen
9
I have read the prescription medication policy as outlined previously, and agree to follow these guidelines. I understand that no medication will be dispensed to my child without written authorization. * This field is required.
Please Select
Please Select
Yes
No
10
I authorize the Jewish Community Day School of Rhode Island to give my child the following prescription medication. I have provided a labeled container with written instructions to the front office* This field is required.
Yes
No
11
Name of medication* This field is required.
12
The dispensing of the above medication will begin at school on:
Date
Month
Day
Year
13
The course of treatment will finish on:
Date
Month
Day
Year
14
The prescription medication being provided is for emergency use (such as an Epi-Pen or Albuterol) and should be given as directed by physician.* This field is required.
Yes
No
15
My child's prescribing physician is:* This field is required.
First Name
Last Name
16
Parent/guardian name* This field is required.
17
Parent/guardian email* This field is required.
18
Date
Date
Month
Day
Year
19
Signature
Clear
20
Date
Date
Month
Day
Year
Should be Empty: