Name of Student_______________________________________________________________
School ______________________________________Grade___________________________
Teacher______________________________________________________________________
Medication ____________________________Dosage_________________________________
Purpose of Medication___________________________________________________________
Time of day medication is to be
given________________________________________________
Possible side
effects_____________________________________________________________
Anticipated number of days it needs to be given at
school_________________________________
______________________________
________________________________________
Date
Signature of Physician
It is understood that the medication is administered solely at the request of
and as an accommodation to the undersigned parent or guardian. In consideration
of the acceptance of the request to perform this service by any person employed
by Cleveland City School System, the undersigned parent or guardian hereby
agrees to release the Cleveland City School System and its personnel from any
legal claims which they now have or may thereafter have arising out of the
administration of or failure to administer the medication to the student.
I hereby give my permission for____________________________________________ to
take the above prescription as ordered. I understand that it is my
responsibility to furnish this medication and agree (by my signature below) that
my child is competent to self-administer his/her medication.
____________________________
______________________________________
Date
Signature of parent/guardian