Student Medication Form
Please fill out this form if your child requires medication to be taken during school hours. Our school nurse, Lowell Saguill, will keep this form for his records.

All records are kept private.

Student Name (Family Name, First Name) *
Your answer
Student's Preferred Name (nickname)
Your answer
Student Grade *
Your answer
Parent's Email *
Your answer
Parent Phone Number *
Your answer
Name of Medication *
Your answer
Reason for Medication *
Your answer
What time(s) of day for medication to be given to student *
Your answer
Special Instructions
Your answer
Other Important Information
Your answer
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