Administration
Academics
Activities
Alumni
Athletics
Calendars
Library
Parents
Staff
Students
Medication Request Form
This COMPLETED form and medication are to be brought to the school nurse. Medication is to be in its original container or one properly labeled by the pharmacy. It should be clearly labeled with:
1. Student's name
2. Drug name and dosage
3. Time it is to be taken
I request the school nurse or administrator supervise my student in taking his/her medication.
I hereby release H.S. District 214, its employees, agents and administration from any and all liability in anyway related to the administration of this medication.
------------------------------------------------------
Parent's Signature
--------------------------------------------------------------------------------------------Student's Name ID #, Year in School
--------------------------------------------------------------------------------------------Diagnosis
-------------------------------------------------------------------------------------------Medication Dosage
-------------------------------------------------------------------------------------------
Time to be administered
--------------------------------------------------------------------------------------------Physician's Signature Physician's Phone
Download pdf version of the Medication Request Form
Body Text 3