Medication Dispensing Authorization Form

Name of Student

First NameLast Name

Name of Medication or Supplement (if you have multiple medications or supplements, you must complete a new form for each)

Reason medication or supplement is given

Dose and time to be given (start and stop date for short term dispensing)

I understand that OASN will NOT dispense any prescribed medication without the original bottle or box. I will ask the pharmacy for an additional bottle for use at OPA/OASN. Additionally, medication, supplements, etc. CANNOT be put into lunches, backpacks, etc.

I furthermore undestand that if there is a seizure plan, this must be supplied to be protective of your child.

Name of Licensed Physician, PA or ARPN Prescribing (write NA for over the counter or supplements ONLY)

Phone Number of prescribing person above

If this is an over the counter medication or supplement-please let us know if this medication or supplement is given daily, as needed, and the reason why the medication or supplement needs to be dispensed onsite. If this is a prescription medicaition, please write NA.

Parent/Guardian Signing this form

First NameLast Name

Email

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

As the parent or guardian of the above listed student, I understand that this medication dispensing form will remain in force until the child is unenrolled from Faith Holistic Academy or our Summer Program, the dosage changes, or the parent no longer wants the medication dispensed (this must be in writing to info@faithholisticacademy.org. Of final note, if you have a medication dispensing form on file for Ocala Preparatory Academy, we must get a new form on file due to our name change).

I hereby authorize theadministration of medication described above to my child by designated Faith Holistic Academy Staff. I hereby indemnify any and allliability of OASN and or Faith Holistic Academy, it’s board of directors, staff, Heritage Management Company, and other entities in the treatment of my child. It is understood by theundersigned that personnel will not be responsible for possible side effectsfrom the administration of the above medication and may contact the physician if there are any concerns about the medication.