The Stonehaven School Medication Administration Form


The Stonehaven School
Medication Administration Form
Student’s Name: __________________________________________________________________
Teacher: _________________________________________ Grade: _________________________
I request that The Stonehaven School, through the principal or designee, supervise/assist
in the administering of medication to my child according to the instructions below. I understand that:
Medications must be in the original labeled container (no baggies foil, etc.) Pharmacies can provide
a duplicate labeled container with only the school doses.
Parent/guardian must provide special instructions, as well as the medication and related equipment
to the principal or school personnel.
It will be the responsibility of the parent/guardian to inform the school of any changes. New
medications or new doses will not be given unless a new form is completed and a newly labeled
container is provided.
All medications will be taken directly to the office by the parent/guardian.
Unused medication will be disposed of unless picked up within one week after medication is
Name of medication: ______________________________________________________________
Dose: _________________________________ Route (by mouth, topical, etc.): _____________
Time(s) to be given: _____________________ Stop medication on: _______________________
Physician’s Name: _______________________ Physician’s Phone: ________________________
I hereby authorize the school personnel, employees and officials of The Stonehaven School to assist my child in taking
prescribed medication according to school policy and I release them from any liability for administering this medication. I
understand that, in the event of a change in medicine, I am responsible for presenting a new request form.
Parent/Legal Guardian
Home Phone __________________ Work Phone ___________________ Cell Phone ____________________________
To be completed by healthcare provider for prescription medications given for more than two weeks.
Condition/Illness Requiring Medication: _________________________________________________
Possible Side Effects if any:_____________________________________________________________
Signature of Healthcare Provider
The Stonehaven School • 505 Atlanta St SE • Marietta, GA 30060 • (770) 874-8885


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