Medical Alert Form School District No. 43, Coquitlam School Board Page 3

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Describe the necessary action or intervention to appropriately treat this medical condition:
 
Step 1 
 
Step 2 
 
Step 3 
 
Step 4 
 
Step 5 
 
Is medication needed? 
 
Yes 
      No   
If yes, what medication?   
Prescribing Physician:   
Parents must complete a Request for Administration of Medication Form (section below) if their child needs medication 
administered at school. 
  
NOTE: No medication will be administered until this section of the medical form is completed. Parents need to ensure that this 
medication does not expire.   It is the obligation of parents to keep a sufficient supply of any required medication at the school.   
 
I have read and verified that the above information is correct.   
By typing your name in the boxes below, you are digitally signing this form. 
 
Parent/Guardian Last Name 
Parent/Guardian First Name
Date
 
 
 
 
Copies to:   
____Parent(s) 
____Student G4 File 
____Medical Alert Red Binder 
_____With medication
 
 
____Nursing Support Care Plan (if necessary) 
 
____TOC Sub book  
_____Child’s Fanny Pack
 
 
    Page 3 of 5 
 

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