Bloomsburg Area School District
Bloomsburg Area School District
Alex J. Dubil Administration Building
728 EAST FIFTH STREET BLOOMSBURG, PENNSYLVANIA 17815-2305 (570) 784-5000 FAX (570) 387-8832
Student attends(circle one): Beaver-Main / Memorial / WWEvans / Middle School / High School
Medication Administration Request Form
To be completed by physician for all medications, including over the counter:
_____________________________________________ (full name of student) must receive the following medication in order to maintain sufficient health to participate in the school program.
Name of Medication: ______________________________________________________
Reason for Administration: ______________________________________________________
Dosage to be administered: ______________________________________________________
Time to be administered: ______________________________________________________
Date(s) to be administered: ______________________________________________________
*EpiPens/Inhalers: Please indicate if student is allowed to carry and self-administer.
_____________________________________________ ________________________
Physician’s Name (printed) Date
____________________________________________ ________________________
Physician’s Signature Physician’s Phone Number
Physician’s Comments: ____________________________________________________________________
________________________________________________________________________________________
I request that school district personnel administer to my child the medication as indicated above. I do hereby release, discharge, and hold harmless the Bloomsburg Area School District and its agents and employees from any and all liability and claim whatsoever for the administration of the above-indicated medication to my child, should a reaction develop because of the medication.
_______________________________________ _____________________________
Parent’s Name (printed) Date
____________________________________________ _____________________________
Parent’s Signature Parent’s Phone Number
2/27/15
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