SAMPLE

XYZ Charter

719 Fourth Street

Anytown, TX

555/555-1234

PARENT’S REQUEST FOR

ADMINISTRATION OF MEDICATION

Date_________________________________

I, the undersigned, who is the parent/guardian of _____________________, ______________

Student’s name Date of Birth

request the following medication(s) be administered to my child.

Medication	Dosage	Time	Refrigeration	Start Date	Stop Date
			Yes/No
			Yes/No
			Yes/No

I understand that the school administrator will appoint a qualified, designated person to perform the above mentioned health care service.

I will notify the school immediately if the health status of ______________________changes,

Student’s name

we change physicians, or the dosage is changed or cancelled.

Signature of parent/guardian ____________________________________________________

Address_____________________________________________________________________

Phone (Home) _________________________ (Work) _______________________________

(Pager) _________________________________(Cell) _______________________________

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