School District Letterhead

SELF-MEDICATION RELEASE FORM

has been instructed in the ProPer

Student's Name: use of the following medication procedures:

We, (Physician's signature) And (Parent or Guardian's be permitted to carry the Request that (Student's Name person or to keep same in his/her locker of P.E. locker as we consider him/her ;;;,;;;;;/;"t purpose and appropriate method and responsible. He/she has been instructed in and understands the

frequency of use.

medication form for those NOTE: This form must be completed in addition to routine district on campus or keep this students who request permission to carry their own medication medication in a P-E. Locker.

Medications in the school setting April 2002 and Laws and Guidelines (8/L2)

of This resource is AppENDtX D - NysED Administration can be located at www.shoolhealthservicesnv'com

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