| REQUEST FOR DISPENSING MEDICATION |
|
SCHOOL DISTRICT OF THE
CITY OF ROYAL OAK REQUEST FOR DISPENSING MEDICATION (To be completed by Parent or Guardian) Student's
Name_____________________________________School_____________________ Address_______________________________________Teacher___________________________ Because the above named student requires medication during school hours, I request that authorized school personnel be permitted to give this medication as directed below. I will provide the medication in an original pharmaceutically-filled container whose label will clearly indicate the physician's instructions for administration and physician's name. Medication Name &
Dosage_______________________________________________________ Possible side
effects:_____________________________________________________________ Signature of Parent or Legal Guardian ______________________________________________ Date_____________ Telephone____________________________________________________ Signature of Physician (Required if medication is for more that ten days): __________________________________________ Date_________ Telephone______________________ |