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Medication form

Posted on March 7, 2013 at 10:45 AM Comments comments (0)

Riverside Public School

Authorization/Parental Consent for Administering Medication

***Please use a separate form for each medication***

Student Last Name: ______________________ First Name: ___________________

Grade: ______

Parental Consent

I am the parent/guardian of ___________________________ . I give permission for him/her to take the following medication while in Riverside School. I hereby acknowledge that I have read and understood the school policy relating to the taking of medications. I hereby release Riverside School and its employees from any claims or liabilities connected with its Reliance on this permission and agree to indemnify, defend and hold them harmless from any claim or liability connected with such Reliance.

_________________________________ ____________________ ___________________

Parent/guardian signature                                  Daytime phone                                     Date


Medication: _____________________________________________________________

Dates medication must be administered at school

___ Short term (list dates to be given) __________________________________

___ Every day at school

Dosage amount: ___________________ Time(s) of day: _____________________

_____ Refrigerate

Send home at the end of the day _____ yes _____No

This student is capable and responsible for self-administering this medication: _____ No _____ Yes (supervised) _____ Yes (unsupervised)