Medication Form by nym11541

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									                                       Forsan I.S.D. - Elbow Elementary
                                      MEDICATION RELEASE FORM
           Parent's request for administration of medication by school personnel.
    This form must be on file in the school office for the school personnel to administer medication, over
                       the counter (i.e. tylenol, advil, benadryl) and /or prescription).
               Please complete this form and return the completed form to the school office.

PLEASE PRINT:

Student's Name:                                                                     Date:


Parent/Guardian's Name:


Physician's Name:


Condition for which medication is to be given:



Name of Medication:                                           Prescription #:

Dosage:                                                       Time to be given at school:


Name of Medication:                                           Prescription #:

Dosage:                                                       Time to be given at school:

Name of Medication:                                           Prescription #:

Dosage:                                                       Time to be given at school:


How long will medication be given?               # Days         # Weeks                 # Months


Special instructions, if any:




            I CERTIFY THAT IT IS NECESSARY TO GIVE THE ABOVE MEDICATION DURING SCHOOL HOURS




Parent/Guardian Signature                                                 Date Signed

                                                                                                   Forsan ISD -03-04

								
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