High School 3305274341 fax [phone]

1
James A. Garfield Schools
Susan Folio, RN

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PARENT PERMISSION FORM Student
Name______________________________________
Date_________________ Address____________________
______________________________________________ Sc
hool______________________________________________
_____________________
I, the undersigned ( ) parent or ( )
guardian of ______________________________________
_ request the following medication be
administered to my child in accordance with the
instructions of _________________________________
_______________________________________________.
student name
physicians name
Medication Name
Dosage
Time to be Administered
I understand the medication must be sent in the
original container in which it was dispensed by
the physician or pharmacist, and also that the
school personnel designated by the building
principal will not be held responsible for the
medication unless such person acts in a manner
that constitutes gross neglect or wanton reckless
behavior. I will notify the school immediately
if the physician changes medication instructions
or terminates the drug. A measuring device will
be sent from home to measure liquid
medication. Parent/Guardian Signature__________
_________________________________
Date_____________________ Address________________
__________________________________________________
_________________ Home Phone____________________
_______________ Business Phone____________________
___________