625
(518) 235-7100 –
Fax 237-1796
PARENT AND PHYSICIAN'S AUTHORIZATION FOR
ADMINISTRATION OF
MEDICATION IN SCHOOL AND SCHOOL ACTIVITIES
A. To
be completed by the parent or guardian:
I request that my child
_____________________________DOB ____________ receive the medication as
prescribed below by our physician. The medication is to be furnished by me in
the properly labeled original container from the pharmacy*. I understand that the school nurse, or other
designated person in the case of the absence of the school nurse, will
administer the medication, including field trips.
Signature(Parent
or Guardian):
________________________________________________
Telephone: Home Work Date _____________
B. To be completed by physician:
I request that my
patient, as listed below, receive the following medication:
Name of Student DOB ____________________
Diagnosis:
_________________________________________________________________
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Medication |
Dosage |
frequency/Time
to be taken |
route of administration |
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Duration of
Treatment:
Possible Side
Effects and Adverse Reactions (if any):
Physician's
Signature Date:______________________
Address: Phone:_____________________
* Medication
must be in original pharmacy labeled container with specific orders and name of
medication.
* Medication and refills must be brought
to school by parent, guardian or responsible adult.
Plan reviewed
with parent(s)/guardian(s):
Parent Signature:_________________________________Date:_______________________