2018-2019 Medication Administration Authorization Form

2018-2019 Medication Administration

Authorization Form

If your child requires medication during the school day, other than the medications listed on the Emergency Contact/Medical Consent Form, this form must be completed and returned to the school nurse along with the medication. If medications can be administered at home, please do so.

Student's Name: ________________________________________________________

Grade: _______________

I hereby request that Mt. Bethel Christian Academy supervise/assist in the administering of medication to my child, ______________________ according to the instructions contained in the statement below.

I understand that:

? Medications must be in the original labeled container (no baggies, foil, etc.) ? All medication will be taken directly to the clinic by the parent. ? Parent/guardian must provide specific instructions, the medication and related equipment

to the clinic. ? It will be the responsibility of the parent/guardian to inform the school of any changes. ? New medication or new doses will not be given unless a new form is completed. ? Unused medication will be disposed of unless picked up within one week after medication

is discontinued.

Name of Medication: _________________________________ Dosage: _____________

Time of Administration: _______________________________ Dates: ______________

Physician's Name: __________________________Physician's Phone: ______________

I release Mt. Bethel Christian Academy and its board of directors, school nurse (RN) and/or any other school employee from liability for administering this medication.

______________________________________________ Date: __________________ Parent/Legal Guardian Signature

______________________ ______________________ _______________________

Home Phone

Work Phone

Cell Phone

MAIN CAMPUS JK-8 4385 LOWER ROSWELL ROAD, MARIETTA, GA 30068

P: 770.971.0245 F: 770.971.3770

NORTH CAMPUS 9-12 2509 POST OAK TRITT ROAD, MARIETTA, GA 30062

WWW.

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