EmailMe Form - Middle School Release for Administering Medication

Name of Student *

First Last

Grade *

Name of Parent/Guardian *

First Last

Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Phone (Home) *

### - ### - ####

Phone (Cell) *

### - ### - ####

Phone (Work) *

### - ### - ####

Email *

Parent/Guardian Consent for Authorized Personnel to Administer Medication

I hereby give my permission for the school nurse or the designated untrained person at school, to give the following:

Name of Medication *

Dosage/Frequency *

Name of Medication *

Dosage/Frequency *

Pain Reducer *

Dosage/Frequency *

I hereby give my permission for my child to self-administer the above listed medication, and I assume responsibility for my child's actions in his/her management of the above listed medication. *

Yes

No

Signature of Parent/Guardian *

Clear