The undersigned(s) are the parent(s), guardian(s), or person(s) in charge of ____________________________________ (student’s full legal name), who is in the ______ grade at the _____________________________ building in the Columbus Community School District.
It is necessary that the above student receive the following medication(s), at the following frequencies, for the following time period (Attach additional sheets if necessary):
(a) __________________________________________________
(Medication)
______________________________________________________
(Frequency (i.e., once at noon, etc.))
Beginning on ___________ and continuing through ____________.
(Duration)
_____ I hereby request the Columbus Community School District, or its authorized representative, to administer the above-named medication to my child named above and agree to this policy:
1. Submit this request to the principal or school nurse;
2. Personally ensure that the medication is received by the principal or school nurse administering it in the container in which it was dispensed by the prescribing physician or licensed pharmacist or is in the manufacturer's container;
3. Personally ensure that the container in which the medication is dispensed is marked with the medication name, dosage, interval dosage, and date after which no administration should be given.
_________________________________ _________________
(Signature of Parent/Guardian) (Date)
_________________________________ _________________
(Printed Name of Parent/Guardian) (Phone Number)