Sunnybeam Medication Consent 2025-2026

Medication Consent
The only medication given by Sunnybeam teachers will be prescription medications authorized by Physicians and Parents having filled in the below Medication Consent form. Prescription medications must be provided to staff in the original prescription container with a child-proof cap and pharmacy label, per the Health Policy guidelines included in the Sunnybeam Handbook.

Please note that this form requires a physician's signature and so cannot be submitted online. Feel free to fill it out here or download blank. Whenever you are ready to preview and save/print this form scroll to the bottom and select "Preview PDF".
Not Applicable
The following section is to be completed by the PARENT OR GUARDIAN:
Students Name*
Class
Birth Date

MonthDayYear
Date
Gender
Health Care Providers Name
Phone
Format: (000) 000-0000.
Address
Fax
I request that authorized persons at school assist my child in taking the medicine(s) described below. I also give my permission forexchange of information between the school district staff and the health care provider.I request that my child be allowed to self-administer medication. I also give my permission for exchange of information between theschool district staff and the health care provider. I shall hold harmless and indemnify Sunnybeam and its employees and agents against all claims, judgments, or liability arising out of the self-administration and carrying of medication of my child.
The following section is to be completed by the HEALTH CARE PROVIDER:
Diagnosis for which medication is given
Name of medicine
Dose
Route
If medicine is to be given DAILY, at what time:
If medicine is to be given WHEN NEEDED, describe indications:
How soon can it be repeated?
YesNo
YesNo
Length of time this treatment is recommended:
Possible side effects:
Emergency procedure in case of serious side effects:
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To preview and print your completed document to send to your health care provider select "Preview PDF below".
Should be Empty:

Medication Consent

The following section is to be completed by the PARENT OR GUARDIAN:

The following section is to be completed by the HEALTH CARE PROVIDER:

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