PHYSICIAN'S REQUEST FOR THE ADMINISTRATION OF MEDICATION BY SCHOOL PERSONNEL

Name of Student _______________________ is under my care and should receive (name of drug, dosage, route) ________________________

at the following time(s)__________________________________________

Specific instructions for administration _____________________________ Possible side effects to watch for ___________________________

Expiration date of this request ____________________________________

Physician's Signature ___________________________________________

Physician's Phone Number _______________________________________

PARENT'S REQUEST FOR THE ADMINISTRATION OF MEDICATION BY SCHOOL PERSONNEL

I hereby request and give my permission to the principal or his/her delegate (or other responsible person) to administer the following medication

to my child.

Name of Student ______________________________________________

Name of Drug _____________________ Dosage _______ Route _______

At the following time(s) ________________________________________

Signature of Parent or Guardian _____________________ Date _________