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MEDICATION FORM
REQUEST FOR ADMINISTRATION OF MEDICATION BY THE IVY SCHOOL
PERSONNEL
I hereby request and give my permission to the principal or school delegate to
administer medication listed below to my child. My signature releases the Ivy School, its
Board, Staff and all representatives of any/all liabilities.
Child name (last)_________________________________ (first)__________________
Date of Birth____________________________________
Medication
Medication Type
(over-counter,
doctor prescribed)
Dose
Interval or Time
Possible side effects to watch for and report to parent/guardian ___________________
_____________________________________________________________________
Parent/Guardian name (print)______________________________________________
Parent/Guardian name (print)______________________________________________
Parent or guardian agrees to notify the person responsible and/or The Ivy School if
there are any changes in medications, including discontinued or a new medicine added,
as well as, change in dose or intervals. This may require filling out a new medication
administration form.
Parent/Guardian consent__________________________________ Date___________
Parent/Guardian consent__________________________________ Date___________
Person administering medication____________________________ Date___________
(signature)
Printed name____________________________________________
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