|
Immaculate
Heart of Mary School
Request
to Administer Medication Form
If you wish your child to be given medication at school, we need the
following information. The purpose is to make sure that your child
receives the prescribed medication and that school personnel know the
expected reactions to the medication. Please send medication to school, in
the original container, with prescription label attached. It is the
responsibility of the parent to submit a new form if the medication is
changed in any way (such as time, route, dosage, or if discontinued).
Medications
that contain narcotics WILL NOT be given during school hours.
Students may carry certain medications as ordered by the doctor and
with the Principal's permission.
During
school hours it is my understanding that trained school personnel will
administer the prescribed medication according to the specified
physician's recommendations. Should the need arise; I give permission for
the school to contact the physician regarding this medication and or the
condition for which it is being administered.
**************************************************************
School:
Immaculate Heart of Mary School
Student's
name:
Date of
Birth:
Address:
Parent/Guardian
's Signature:
Date of
Signature:
Home Phone #:
Work Phone #:
**************************************************************
To
Be Completed By The Child's Physician
Name of
medication:
Dosage:
Time(s) administered:
Reason
mediation is to be given:
Possible side
effects:
Physician 's
signature:
Date:
Physician's
Name:
Phone:
Physician's
Address:
|
School Nurse