Parent's Request for Administering Medication at School
I understand that the medication will be furnished by me in the original pharmacy ontainer and must be labeled with my child’s name, name of medication, dose to be given, time(s) to be administered, route of administration and prescribing physician.

I understand that all medications ordered once or twice a day should be given at home unless ordered for a specific time during school hours.

I understand that it is the responsibility of my child to seek out the school nurse or designated personnel at the approximate time of administration whenever possible.

I understand that a medically untrained designee of the principal will administer this medication in the absence of the school nurse.

I understand that the principal and/or school nurse may call the physician if there are any questions regarding the safe administration of this drug.

I understand that the school nurse or designee will notify me if this medication is withheld in the best interest of my child.

I understand it is my responsibility to replenish the supply of medication in a timely manner, upon notification by the school nurse.

I request school personnel to give my child medicine. (Child's name/ date of birth)
Your answer
Name of Medication
Your answer
Medication Dosage
Your answer
Time of Day
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Reason for Medication
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Duration of Medication to be given
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My child is allergic to the following medication(s):
Your answer
Parent/Guardian Signature
Your answer
Date
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YYYY
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