Change Form
What information would you like updated/changed in our records?
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Authorized Pick-Up Change
Over-the-Counter Medication Administration Change
Prescription Medication Change (including dosage change)
Allergy Change
Address Change
Diagnosis Change
Other
Which over-the-counter items can be administered?
Acetaminophen
Ibuprofen
Antibiotic Ointment/Cream
Hydrocortizone Cream
Acid Reflux Medication
Sunscreen
Other
Note, all medication should be in original packaging and not be expired.
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Yes, I understand.
If multiple medication changes are requested, please submit a separate change form for each medication change.
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Yes, I understand.
OK. What change are you requesting?
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Please provide sufficient detail
Student's Name
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First Name
Last Name
Student's Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Parent's Name
*
First Name
Last Name
Parent's Signature
*
Submit
Should be Empty: