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:


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Shalom Health Care Center
https://www.shalomhealthcenter.org

Signature Certificate
Document name: Med Administration Consent- English
lock iconUnique Document ID: 6a2548f50509047428f08ab367adaa3ab26a0a78

Timestamp Audit
May 7, 2019 3:05 pm EDT Med Administration Consent- English Uploaded by Darren Huff – [email protected] IP 75.118.54.214
May 7, 2019 4:47 pm EDT Forms 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 EDT Forms Admin – [email protected] added by Darren Huff – [email protected] as a CC’d Recipient Ip: 74.199.20.27