Infant Of Prague Catholic School
Request for Medication
(To Be Given During School Hours)
TO BE COMPLETED BY PARENT OR GUARDIAN (all lines must be completed)
Name of Child
__________________________ Date
Medication
Strength
____________
(i.e. 10 mg. etc.)
Dosage ______________________ Route of administration __________________
(i.e. 2 tabs, 2 tsp, etc.) (by mouth, in ear, etc.)
Medication Description ________________________________________________
(white tablets, purple liquid, etc.)
Time (s) to be administered _____________________________________________
My child will receive this medication on a daily basis. YES NO
(circle one)
Dates child is to receive this medication: from __________ to ____________
Special instructions (if applicable): _______________________________________
__________________________________________________________________
All prescription medication must be in their original labeled containers. Label must include the child’s name, the Doctor’s name and proper dosage information. All other medication must be in their original containers. Cough drops must be turned into the office.
I hereby give permission for my above named child to receive this medication during school hours. I understand that the school undertakes no responsibility for the administration of this medication. I hereby release Infant of Prague Catholic School and it’s agents and employees from any and all liability that may arise from my child taking this medication.
______________________________________
Parent or Guardian Signature