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POPE JOHN PAUL II REGIONAL CATHOLIC
ELEMENTARY SCHOOL 2875 Manor Road 610-384-5961 West Brandywine,PA 19320 610-384-5730 – fax CONSENT FORM FOR ONGOING PRESCRIPTION MEDICATION AND OVER THE COUNTER MEDICATION Date: ___________
TO SCHOOL NURSE: As the parent/guardian of _____________________________________, I request that school personnel administer the enclosed medication to my child according to the directions from the physician. I hereby release the Coatesville Area School District School Board and its employees of liability for administration of medication. I understand ANY medication sent to school MUST be in its original container. If it is not, the medication will not be dispensed. Name of Medication: ____________________________________ Dosage to be administered: _______________________________ Time medication is to be given: ____________________________ Date(s) medication is to be given: __________________________ Condition being treated: _________________________________
_________________________________ Signature of Parent/Guardian |