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