Reynoldsburg City Schools

PARENT’S REQUEST FOR THE ADMINISTRATION OF NON-PRESCRIPTION MEDICATION AT SCHOOL

To be completed by parent/guardian:

I request the school nurse, building principal, or designee to administer the non-prescription medication named below to my child. I will hold the school personnel harmless for the administration of the medication described below because they are not legally obligated to administer medication to my child.

Student’s Name: ______________________________________________________________

Student’s School: ______________________________________________________________

Student’s Address: ______________________________________________________________

Name of Medication: _____________________________________________________________

Dosage to be administered: _______________________________________________

Times or intervals at which each dose should be given: _________________________

Reason for medication: _____________________________________________________________

Date administration is to begin: ______________________________________

Date administration is to end: _______________________________________

Name and phone number of the physician to be called in case of an emergency:

_______________________________________		_________________________________________

Signature of Parent/Guardian				Date

Address of Parent/Guardian			Home Phone			Work Phone

To be completed by School Personnel:

Nurse’s signature:_____________________________	Date: __________________________

Principal’s signature: __________________________	Date: __________________________

Designee’s signature: __________________________	Date: __________________________