Summit Academy Medication Administration Form


Summit Academy Medication Administration Form
Student’s name:_______________________________________ Grade: _________________
Date of birth:_____________________ Room Color: __________________________
Condition for which drug is being administered:_______________________________________
Medication:_________________________________ Dosage:___________________________
Hours to be given at school:__________________________________
For a period from_____________________________ to _______________________________
Restrictions and/or side effects:____________________________________________________
Additional comments: ___________________________________________________________
Physician Name (Please print)
Physician Signature
Address and City
Telephone Number
I request that my child ______________________________receive the above medication at
school according to school policy ordered above by his/her physician.
Parent/Guardian Signature
Policy: Medication includes both prescription and non-prescription medicine. The proper
form, which includes written permission from the parent/guardian must be filled out and
returned to the office before medication can be dispersed. The form will also include written
instructions. All medications will be administered by the Administrator, teacher, or other
designated adult and in the presence of another adult. Medication must be brought into the
office by the parent/ guardian. Medication must be in an original, labeled container.


00 votes

Related Articles

Related forms

Related Categories

Parent category: Education