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