Parents Request For Administration Of Mediation Form printable pdf download

PARENTS REQUEST FOR ADMINISTRATION OF MEDICATION

BY SCHOOL PERSONNEL

Name of Pupil________________________________________ Date of Birth _____________________

Teacher_____________________________________________ Grade___________________________

I do hereby request that school personnel of the Frisco Independent School District administer the

medication set forth below to my child. The medication must be administered during school hours and I cannot

personally supervise this activity. I have supplied all information concerning the dosage of the medication and

method of administration or requested that it be supplied by my child’s physician. I do hereby release the Frisco

Independent School District, its agents, servants, employees and medical advisors from any liability in

connection with the administration of this medication.

I understand that my child requires medication(s) to be on hand during field trips away from the school

campus. I give my permission for the school to send this medication (these medications) on the field trip with my

child. All medication(s) will be sent in a single dose container if possible and clearly marked with my child’s

name and instructions. An assigned teacher who has been given instructions, has verbalized understanding of

medication administration and has performed demonstration of medication administration, will be in charge of

dispensing the required medication as directed on the field trip.

Medication: ________________________________

Time: _____________________________________

Start Date: _____________ End Date: ___________

Start Date: ____________ End Date:____________

Dosage and Route: __________________________

Special Instructions:

__________________________________________

Physician’s Name_____________________________________ Phone Number______________________

Physician’s Signature (if needed) __________________________________Date ______________________

Parent’s/Guardian’s signature_________________________________________ Date__________________

Information concerning this medication and my child’s health may be shared with/obtained from the above

named physician. Parent’s signature__________________________________________Date_____________

Parents Request For Administration Of Mediation Form