School District Of Crandon Medical Release Form printable pdf download

School District Of Crandon Medical Release Form

School District of Crandon Medical Release Form

All portions of this medical request form must be completed before medication can be administered by school district

personnel. Prescription medications require a physician’s signature.

STUDENT: ______________________________

SCHOOL ____________________________

GRADE: _____________

TEACHER: ___________________________

NAME OF MEDICATION __________________________________________________

STORAGE REQUIREMENTS: _______________________________________________

DOSAGE: ___________

TIME(S) TO BE GIVEN: _______________________________

HOW TO BE GIVEN (oral, injection or other).

EXPLAIN: ___________________________________________________________________________________

REASON FOR MEDICATION:

_____________________________________________________________________________________________

DATE OF DISCONTINUATION: _____________________________

Explain possible reactions or other instructions: ______________________________________________________

PHYSICIAN’S NAME: ___________________________ PHYSICIAN’S PHONE ______________

The school personnel have my permission to administer this medication as indicated above. I agree to hold the School

District of Crandon, its employees or agents who are acting on this request, harmless in any and all claims arising from

the administration of this medication at school. I also agree to inform the school immediately and in writing of any

change in the medication order.

I further give permission to the school authorities to contact the child’s physician, if necessary.

Parent/guardian signature: _________________________________

DATE: _____________

Home phone number: ______________________

Work phone number: ____________________

PHYSICIAN AUTHORIZATION

The physician whose signature follows hereby authorizes school personnel to administer medication as prescribed and

also agrees to accept communication regarding the administration procedures. It is understood that the medication will

be given by non-licensed, but specially trained personnel. The reason(s) that the medication must be given during the

school day should be given.

Medical rationale for medication to be given during the school day:

Physician’s signature: __________________________ Phone # _________ Date _________

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School District Of Crandon Medical Release Form