Shalom School-Based Clinic Consent to Administer a Medication
Student's name
*
First Name
Last Name
Date of birth
*
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Month
-
Day
Year
Date Picker Icon
School
*
Allison Elementary
Anna Brochhausen IPS 88
Brookside Elementary IPS 54
Carl Wilde IPS 79
Charles Fairbanks IPS 105
Clarence Farrington IPS 61
Daniel Webster IPS 46
Eleanor Skillen IPS 34
Enlace Academy
Fisher Elementary
George Washington Middle School
Global Prep Academy
Harshman Middle School
IMSA-Central
IMSA-North
IMSA-West
James Garfield IPS 31
James Whitcomb Riley IPS 43
Lew Wallace IPS 107
Matchbook Learning
Newby Elementary
Northwest Middle School/Monarca
Ralph Waldo Emerson IPS 58
Sankofa
Shortridge High School
Speedway Junior High School
The Path School
Thomas Gregg Neighborhood School
Washing Irving Neighborhood School
Wheeler Elementary
William McKinley IPS 39
Other
School
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Medication name and dosage
*
Instructions, including time to give medication
*
Med type
*
Over the counter
Prescription
Controlled
For late or delayed arrival, please
*
Give medication when they arrive at the clinic
Hold medication if they arrive after a set time
Contact me before giving medication
Not applicable
Your initials
*
for the late or delayed arrival instructions
Hold the medication if they arrive after
For early or alternate dismissal, please
*
Give medication at a set time
Hold the medication
Contact me before giving medication
Not applicable
Your initials
*
for the early or alternate dismissal instructions
Give the medication at
I authorize clinic staff to administer the medication as described here. Medication(s) will be stored in a secure location in the clinic.
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Your initials
My authorization will be in effect until a termination or change in medication is submitted in writing, or at the end of the school year.
*
Your initials
I understand all medications will be counted in with SBC staff and the parent/adult dropping off medication, or an adult school staff witness. All medications must be labeled. Prescription medications must have a valid pharmacy label. Medication(s) may only be labeled for one student.
*
Your initials
Any medication left in the clinic past the last day of school will be wasted/destroyed per Indiana state law.
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Your initials
I agree it is my responsibility to notify clinic staff of any changes immediately and in writing. This may be done electronically through my child's patient portal.
*
Your initials
Please notify me when my child has the number of doses below left of their medication, to allow adequate time to get a refill.
*
Your initials
Notify me when this many doses remain
*
Please contact me by
*
Text message
Email
Phone call
Text me at
Format: (000) 000-0000.
Email me at
Call me at
Format: (000) 000-0000.
Signature
*
Date
*
-
Month
-
Day
Year
Date Picker Icon
Your name
*
First Name
Last Name
Daytime phone number
*
Format: (000) 000-0000.
Relationship to student
*
Email
*
parent name (PDF)
Submit
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