AUTHORIZATION TO GIVE MEDICATION AT SCHOOL

If medication can be given at home or outside of school hours, please do so. However, if medication MUST be given during school hours, this form must be completed and returned to school.

STUDENT NAME ______________________________________ GRADE ____________

TEACHER/TEAM ______________________________________

I hereby request that FCMS, through the principal or designee, supervise/assist in the administering of medication to my child, ______________________________, according to the instructions contained on the statement below.

I understand that:

• Medication MUST be in the original labeled container (no baggies, foil, etc).
• Parent/guardian must provide specific instruction, as well as the medication and related equipment to the principal/designee.
• It will be the responsibility of the parent/guardian to inform the school of any changes.
• All medication will be taken directly to the clinic/office by the parent.
• Unused medication will be disposed of unless picked up within one week after medicine is discontinued.

NAME OF MEDICATION: ________________________________________________________

DOSAGE AND TIME OF ADMINISTRATION: ________________________________________

STOP MEDICATION ON: ________________________________________________________

PHYSICIAN’S NAME: _____________________________ PHYSICIAN’S PHONE: _________

I release the school board, the school, and any school employee from any liability for administering this medication.

____________________________________________ ___________________

Parent/Legal Guardian Signature Date

Phone Numbers

Home: ______________ Work: _______________ Cell: _____________________

To be completed by healthcare provider for prescription medication:

Condition/illness requiring medication: ______________________________________________

Potential side effects, if any: ______________________________________________________

__________________________________________ ___________________

Signature Healthcare Provider Date