Sjn Form 6 - Medication Consent Form printable pdf download

SJN Form #6

FIRST INITIAL OF LAST NAME ________

CLASS ________

MEDICATION CONSENT FORM

2015 – 2016 School Year

All prescription and non-prescription (over-the-counter) medications must be

accompanied by a Medication Consent Form signed by the student’s physician.

Prescription medication must be in its original container. Non-prescription medication must be

in its original sealed container with a label stating the child’s full name, name of drug and

dosage, time to be given, and physician’s name.

Parents may make the label for non-

prescription medication. Students must supply their own over-the-counter medication.

Name of School:

St. John Neumann Regional Catholic School

Address of School: 791 Tom Smith Road Lilburn, GA 30047

Phone # of School: 770-381-0557

Fax # of School: 770-381-0276

Full name of child to receive medication: ___________________________________________

Name of drug and dosage: ______________________________________________________

Prescription # _________________________________________________________________

Hour(s) medication to be given: _______________ Dates to be given: ____________________

Reason for medication: _________________________________________________________

Possible side effects to watch for: _________________________________________________

Name of Physician prescribing medication: __________________________________________

Signature of physician prescribing medication: _______________________________________

Physician’s phone number: ______________________________________________________

I hereby give permission to the Clinic/Office Personnel to give the medication(s) to my child

according to the directions stated above and further authorize them to contact the child’s

physician. I agree to hold the above-named school, its employees and agents who are acting

within the scope of their duties, harmless in any and all claims arising from administration of this

medication at school.

I agree to notify the school, in writing, at the termination of this request or when any change in

the above order is necessary.

_________________________________________________________ _________________

Signature of Parent/Guardian

Date

____________________________________________________________________________

Address

______________________

________________________

_______________________

Home Phone

Work Phone

Cell Phone

Sjn Form 6 - Medication Consent Form