Medication Dispensing Authorization Form
Name of Student
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First Name
Last Name
Name of Medication or Supplement (if you have multiple medications or supplements, you must complete a new form for each)
*
Reason medication or supplement is given
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Dose and time to be given (start and stop date for short term dispensing)
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I understand that OASN will NOT dispense any prescribed medication without the original bottle or box. I will ask the pharmacy for an additional bottle for use at OPA/OASN. Additionally, medication, supplements, etc. CANNOT be put into lunches, backpacks, etc.
I understand this.
I furthermore undestand that if there is a seizure plan, this must be supplied to be protective of your child.
*
I understand this
Name of Licensed Physician, PA or ARPN Prescribing (write NA for over the counter or supplements ONLY)
*
Phone Number of prescribing person above
*
If this is an over the counter medication or supplement-please let us know if this medication or supplement is given daily, as needed, and the reason why the medication or supplement needs to be dispensed onsite. If this is a prescription medicaition, please write NA.
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Parent/Guardian Signing this form
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First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
As the parent or guardian of the above listed student, I understand that this medication dispensing form will remain in force until the child is unenrolled from Ocala Preparatory Academy or the OASN Summer Program, the dosage changes, or the parent no longer wants the medication dispensed (this must be in writing to kvega@oasn.info).
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I hereby authorize theadministration of medication described above to my child by designated OASN Staff. I hereby indemnify any and allliability of OASN (including it's subsidiary company, Ocala Preparatory Academy), it’s board of directors, staff, Heritage Management Company, and other entities in the treatment of my child. It is understood by theundersigned that personnel will not be responsible for possible side effectsfrom the administration of the above medication and may contact the physician if there are any concerns about the medication.
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Submit
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