Port Washington-Saukville School District

 

AUTHORIZATION TO ADMINISTER MEDICATION

 

PARENTAL CONSENT FOR NON-PRESCRIPTION MEDICATION

 

 

Name of Student:______________________________����������� Date of Birth:________________

 

School:_______________________________________��� Grade:_______________________

 

Names of Parent(s)/Guardian: _____________________________________________________

 

Phone: (Home) __________________________���� (Work) ______________________________

 

I give permission for my child to receive over-the-counter medication during school hours.

 

I will be responsible for:

1)      Delivery of medication in an original manufacturer�s labeled container to the school office

2)      Maintaining a sufficient supply of medication

3)      Keeping school personnel informed of changes in the medication (dosage, time)

 

I hereby release the Board of Education and its agents and employees from any and all liability that may result from my child taking the prescribed medication.

 

 

______________________________________��� ����������� ______________________________

����������� (Parent/Guardian Signature)������������� ������������������������������� ������������������������������� ��������������� (Date)

 

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Name of Medication����������� Dosage����������������������� ����������� Form* ����������� Time��� ����������� Possible Side Effects

�� (Generic and Trade)��������������� (mg/cc/tsp/gtt)��������������� ��������������� (tab/cap/liq)��������������� a.m./p.m. �����������������������     

 

 

 

*Prior to administration of medication by routes other than oral, school personnel must contact the school district nurse for instruction.

 

I understand the above information may be shared by the school principal with necessary school personnel.The above request shall remain in effect through ___________________, unless parent/guardian withdraws the request in writing.�����������������������          (Date)

 

 

 

For School Use Only

 

1.        Date Received:__________________________

2.        Name of Person (s) who will administer the medication:

______________________________________________ _______________________________________________


3.        Approved by: __________________________________________________ _______________________________

(Signature of Principal) (Date)