Med Administration Consent- English


 

 

 

REQUEST TO ADMINISTER MEDICATION TO STUDENT DURING THE SCHOOL DAY
If it becomes necessary for a student to take medication or receive treatment during the school day, the parent or guardian must complete this request form and turn it in to Shalom’s Health Care Clinic.  If the medication or treatment is physician prescribed, the parent or guardian must submit a written prescription from the child’s physician or the pharmacy label with the request.  This request is in effect until a termination or change in medication is submitted.  All requests are terminated at the end of the school year.
PARENT OR GUARDIAN’S AUTHORIZATION
I request that the medication described below be administered to my child/ward at the time specified during the school day.  I will give the healthcare staff the medication in it’s original labeled container. Prescribed medication will be labeled with the student’s name and the exact dosage. 
I understand this medication will be administered to my child only by authorized staff members and will be kept secure in a cabinet or refrigerator. 

       

   

 

     

     

I give permission for my child to transport medication to and from school: 

 

Leave this empty:

Shalom Health Care Center https://www.shalomhealthcenter.org
Signature Certificate
Document name: Med Administration Consent- English
Unique Document ID: b4839e0c37386d4a3888b01da9bfe234a9d4bef2
Timestamp Audit
May 7, 2019 3:05 pm EDTMed Administration Consent- English Uploaded by Darren Huff - [email protected] IP 74.199.20.27
May 7, 2019 4:47 pm EDTForms Admin - [email protected] added by Darren Huff - [email protected] as a CC'd Recipient Ip: 74.199.20.27
May 7, 2019 4:58 pm EDTForms Admin - [email protected] added by Darren Huff - [email protected] as a CC'd Recipient Ip: 74.199.20.27