ADMINISTRATION OF MEDICATION

Date

Discontinued

Date

Received

2007-2008

Parent Initials____

Student’s Name: ________________________________ Grade ______ Teacher _________________________

Amt. Of Medication Received ____________________ Prescribing Physician’s Phone Number _______________

Name and Number of Prescribed Medication ____________________________________________________________

Time and amount to be given at School __________________________________________________________________

Possible Side Effects or Special Instructions ______________________________________________________________

I request and authorize the school to dispense this medication in accordance with the physician’s instructions.

___________________________________ _______________________ _______________________

Parent’s Signature Date Home Phone Work Phone

Date

Time

Amt.

Comments/Initials

Date

Time

Amt.

Comments/Initials

____________________________________________________ ___________________________________________________

Signature and initials of administrator of medication Date Signature and initials of administrator of medication Date

____________________________________________________ ___________________________________________________

Signature and initials of administrator of medication Date Signature and initials of administrator of medication Date