507.2E1 Permission To Administer Medication

PERMISSION TO ADMINISTER MEDICATION


Student: ___________________________________ D.O.B. _______________________

School: ____________________________________ Grade: ________________________


Date: ______________________________________


To Be Completed by Parents / Guardian

I hereby give permission for Lewis Central School to administer medication as prescribed below to my child ______________________________________. During the school hours, it is my understanding that a licensed nurse or medication certified staff will administer the prescribed medication according to physician’s orders to my child. Your signature on this form will give us permission to contact this prescriber if we feel it is necessary.
___________________________________
Parent’s Signature


To Be Completed by Physician

Medication: _______________________________________________________________________________

Recommended Dosage: ______________________________________________________________________

Time(s) to be administered: ___________________________________________________________________

__________________________________________________________________________________________

Possible side effects: ________________________________________________________________________

_________________________________________________________________________________________


___________________________________
Prescriber’s Signature


Thank You,



Nurse / Health Associate

Phone: __________________ Fax: _____________________

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