Administration of Non-Prescription Medication

Administration of Non-Prescription Medication

Berne Union Local Schools
Berne Union Local Schools does not wish to dispense medication at school unless absolutely necessary. If it is necessary to give non-prescription medicine during the school day for the child's well-being, please complete the following information.
Student Name:
Grade:
Name of Medication:
Dose:
Specific Time(s) to be Administered:
Reason for Medication (type of illness, condition):
As the parent or guardian, I agree ... (you must check all or form will be invalid)
Signature of Parent/Guardian
Parent/Guardian's Email
example@example.com
Date

MonthDayYear
Date
Should be Empty: