Otsego Elementary School Faculty Handbook - Half Hollow Hills

CONSENT FOR ADMINSTRATION OF MEDICINE
Half Hollow Hills
Central School District
Otsego Hill Elementary
Parent and Prescriber’s Authorization for Administration of Medication in School
A
To be completed by the Parent or Guardian:
I request that my child ___________________, receive the medication as prescribed
below by our physician. The medication is to be furnished by me in a properly labeled
original container from the pharmacy, and a second labeled container is to be provided (if
necessary) for field trips. I understand that the school nurse will administer the medication
at school as directed.
___________________________________
Parent/Guardian Signature
____________
Date
_____________________________________________________________________________
Address Street City Zip
_____________________________________________________________________________
Telephone Home Work Cell
To be completed by the Physician:
B I request that my patient, as listed above, receive the following medication at school:
Diagnosis:
Medication:
Prescribed Dosage/Frequency/Time & Route Administration:
Possible Side Effect/Adverse Reactions (if any):
Other Recommendations:
Physician’s Name (please print):
_______________________________
Physician’s Signature
____________
Date
_____________________________________________________________________________
Address Street City Zip
_________________________________________
Phone