625
(518) 235-7100 –
Fax 237-1796
SELF MEDICATION RELEASE FORM
Date: _________________
Child’s
Name:
___________________________________________________
has been
instructed in the proper use of the following medication procedures:
We,
(physician’s signature)___________________________________________
and (parent or
guardian’s signature) __________________________________
request that
(child’s name) ___________________________ be permitted to carry the medication
on his/her person or to keep same in his/her locker or P.E. locker, as we
consider him/her responsible. He/she has
been instructed in and understands the purpose and appropriate method and
frequency of use.
NOTE: This
form must be completed in addition to routine district medication form for
those students who request permission to carry their own medication on campus or
keep this medication in a P.E. locker.