Beachwood City Schools Non-Prescription Medication Administered by School Personnel To Be Completed by Parent/Guardian: School: ___________________________________

Grade: ___________________

Student Name: _____________________________

Date of Birth: ____________________

Name of Medication: __________________________________________________________ Reason for Medication: ________________________________________________________ Dosage: ____________________________________________________________________ Time and Frequency: __________________________________________________________ Special instructions: ___________________________________________________________ Reactions to be reported to parent or doctor: _______________________________________ ___________________________________________________________________________ Physician's Name: __________________________

Phone Number: __________________

I give permission for my child to receive medication at school according to school district policy and agree to: • Assume responsibility for safe delivery of the medication in its original container to the school • Have a new form completed if medication or dosage is changed • Notify the school of changes in health care provider Further, I hereby release from liability, and in addition agree to indemnify, all school employees and the Board of Education for damages or injury resulting from the use, misuse or nonuse of such medication except as such Board or its employees are grossly negligent or engage in wanton or reckless misconduct. Parent’s Signature: ________________________

Date of Signature: __________________

Home Phone Number: ______________________

Business Number: __________________

**Return completed form to school nurse* THIS FORM WILL EXPIRE AT THE END OF THE SCHOOL YEAR