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Medication Consent Form



ERVING SCHOOL UNION #28

18 PLEASANT STREET

ERVING, LEVERETT, NEW SALEM, WENDELL, SHUTESBURY

ERVING, MA 01344

413 423-3337

FAX 413 423-3236

www.erving.com


PARENT/GUARDIAN CONSENT FOR MEDICATION ADMINISTRATION


(Please print)

Name of Student_______________________________________

Date of Birth_________________ Sex ______

School___________________________________________________________ Grade____________________

Name of Parent/Guardian______________________________Address_________________________________

Home Phone_____________________________________

Work Phone__________________________________


Other person to be notified in case of emergency if parent/guardian is unavailable:

Name_________________________________Telephone____________________

Relationship_______________


My son/daughter is currently receiving the following medications (to be completed if not in violation of confidentiality):

1 ____________________ 2 _____________________ 3 ____________________

4 _____________________


My son/daughter is known to have the following allergies______________________________________________


I give permission to have the school nurse, or school personnel designated by the school, to give the following medicine_______________________________________ (name of medicine)

prescribed by______________________________ (licensed prescriber) to

____________________________ (name of student) at _______________ (time) for the following

period_________________________ (beginning date to ending date).



A before school dose will be given at _____________________________. (time before school)




I give permission to the school nurse to share with appropriate school district personnel information relative to the prescribed medicine administration, e.g., adverse side effects, as she/he determines necessary for my son╩╝s/daughter╩╝s health and safety.


YES ______ NO ______ Any restrictions on release ______________________________


__________________________________________________________________________

Please note, I understand that I may retrieve the medicine from the school at any time and that the medicine will be destroyed if it is not picked up within one week following the termination of the order or one week beyond the close of school.


Signature of Parent/Guardian __________________________________________________________________

Relationship to Student: _______________________Date: ______________________


Erving School Union #28 assures that all programs, activities and employment opportunities are offered without regard to race, color, sex, age, creed, homelessness, religion, national origin, sexual orientation and disability.