Medical Administration Form Student Name: ___________________________________________________ Date: ___________________ Birthday: ________________________ Grade: _____________________ Gender:

male

female

□ I request that the below listed medication(s) be administered to my child during the school day.

Parent Name: ____________________________________________________ Date: ___________________ Parent Signature: __________________________________________________ Daytime Phone Number: ____________________________________________

Medication: ___________________________ Dose: ___________________ Time(s) Given: ______________ Prescription Medication Amount: _____________ Staff Initial: _____________ Exp. Date: ________________ Purpose: ______________________ Additional Information: _______________________________________

Medication: ___________________________ Dose: ___________________ Time(s) Given: ______________ Prescription Medication Amount: _____________ Staff Initial: _____________ Exp. Date: ________________ Purpose: ______________________ Additional Information: _______________________________________

Medication: ___________________________ Dose: ___________________ Time(s) Given: ______________ Prescription Medication Amount: _____________ Staff Initial: _____________ Exp. Date: ________________ Purpose: ______________________ Additional Information: _______________________________________

Comments: (additional medication sign in, medication sign out, parent contact and other documentation _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________