Parent Permission for the Administration of Over-The-Counter Medication - Grades 9-12
Email address *
Student LAST Name *
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Student FIRST Name, Middle Initial *
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Any known food or drug allergies
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Grade *
I give permission for the following medication to be given to my child by designated school personnel: Please check all that apply.
Medication can be given for the following conditions:
Other condition, please specify
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THIS ORDER WILL BE IN EFFECT FOR THE CURRENT SCHOOL YEAR.
Parent Signature. By submitting you are signing this Agreement electronically. *
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Parent Email
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Date
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YYYY
Home Phone *
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Work Phone
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