Student Name:
Date of Birth:
Age:
Grade:
Classroom:
Reason for medication:
Medication:
Medication Name | Start Date | Stop Date | Dosage | Route | Frequency | Side Effects | ||
|---|---|---|---|---|---|---|---|---|
A | B | C | D | E | F | G | ||
1 | ||||||||
2 | ||||||||
3 | ||||||||
4 |
Emergency Contact:
Describe | Name | Phone Number | ||
|---|---|---|---|---|
A | B | C | ||
1 | Parent / Guardian | |||
2 | Health Care Provider | |||
3 | Pharmacy |
Health Care Provider Signature:
I give permission to my child, (child’s name), to be given the above medication(s) as prescribed. And I should notify the school of any changes.
Parent / Guardian Signature:
To configure an element, select it on the form.