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            Name of School
RE:                                                                                   Grade:                        Age:                       
            Name of Student/Patient


The above named person is a patient of mine and is currently under my medical care. Because of the medical condition below, medication needs to be given during regular school day according to the following protocol:

Medication:                                                                         Dosage:                        Time:                
         Brand or Generic Name

Reason for Medication:                                                                         

Directions for Giving Medication:                                                       ___

Possible Side Effects:                                                                        

If an emergency situation occurs during the school day or if the pupil becomes ill, school staff is to:

     a.Contact me at my office:
     b.Take child immediately to the emergency room at:
     c.Other option:

I am aware that non-medical personnel will administer this medication, and in my opinion, this medication is necessary during school hours.

            Date                                          Physician’s Signature
I, the parent/legal guardian of                                        , enrolled at           _____
Realizing the importance of administering medication to my child as prescribed by the child’s physician, do hereby agree to relieve designated school personnel of any liability from any potential ill effects as a result of their injection or giving my child the medicine prescribed by the child’s physician. I have discussed this with my physician and/or legal counsel and realize its ramifications and thoroughly understand the meanings of these statements.
Parent or Guardian’s Signature                                                     Date                         
Principal’s Signature                                                                     Date                                                                           
Name of child:                                                                                          
I request and authorize the administration of:
Medication:                                                    Dosage:                                    Time:                          
I understand that school personnel will administer this medication and are not medically trained. I agree to the following conditions:
         1)The school will be supplied with medication in a container appropriately labeled
             by the pharmacy, stating the name of the student, the medication, the dose,
             the pharmacy and the date.
          2)A responsible person will bring the medication to the school.
          3)The parent/guardian will notify the school nurse of any change in dosage.
Parent or Guardian’s Signature                                   Date                                                                                           
School Nurse                                                             Date                                                                                                               

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