Medication Administration Authorization
For prescribed medication to be administered at Muneer Academy
Student's Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Condition for which drug is being administered:
*
Medication Name
*
As it appears on the label
Frequency
*
As it appears on the label
Time to Administer
*
Dosage
*
Allergies
*
No
Yes
Relevant Side Effects
*
No
Yes
If Yes, Specify:
If Yes, Specify:
Additional information
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Medical Provider's Full Name
*
First Name
Last Name
Medical Provider's Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Parent/Guardian authorization for self-administration:
*
Yes
No
Date that consent given
*
-
Month
-
Day
Year
Date
Parent Name
*
First Name
Last Name
Parent Email
*
example@example.com
Parents Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Terms and Conditions
Medication must be all medication should be in original named box / bottle and always labelled with the child’s name, DOB, dose and date. (dispensed from the pharmacy). Please supply a measured medicine spoon / syringe. Please give staff all the information required to insure the well-being of the child. All labels should be clear and specific: Name, Reasons, Dosage, Signs, and Symptoms
Agreement to terms and conditions
*
I, the undersigned, hereby authorize the administration of the above-named medication to my child, as prescribed by the medical provider, while they are at school.
I understand that this authorization is valid for the specified dates and dosage mentioned above.
I acknowledge that the medication must be delivered to the school office by a parent or legal guardian and that students are not allowed to bring medication to school.
I will promptly inform the school office of any changes in my child's medication.
At least one dose of the medication has already been administered and my child has not suffered any unwanted reactions.
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