Greeneview Schools
Administration Of Oral Medication At School
Primary Bldg Fax # 937-675-2438;  Intermediate Bldg Fax # 937-675-6866; HS Fax # 937-675-6805

DOCTOR AND PARENT SIGNATURES REQUIRED

Student Name
Grade
School Attending
Parent/Guardian
Date
Street
City
State/Zip
Home Phone Number
Emergency Phone Number

PARENT(S)/GUARDIAN RELEASE
We (I) the undersigned who are the parent(s), foster parent(s), guardian(s), (cross out those NOT applicable) of:
request that oral medication be administered to our child in accordance with the                 Student's Name           instructions of our physician named below.

We(I) understand that the administration of said medications is to be done under the supervision of a member of the school staff.

Further, we(I) understand that the school personnel are not legally obligated to administer oral medication to any child and, therefore, we(I) agree to hold the school district and its employees free from any and all responsibility for the results of such medication or the manner in which it is administered and to indemnify each of them against loss by reason of any civil judgement arising out of these arrangements which may be rendered against them

Further, we(I) will notify the school immediately if we change physicians or medication or terminate the use of this medication for any reason.

______________________________________________________
Signature of Parent(s) or Guardian Date

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PHYSICIAN'S REQUEST
Since oral medication to the student will be administered by untrained personnel it is necessary that the following information be given to the school.  Please fill out this form completely in order for the administration of any prescribed medication to begin.

1.
Medication to be administered (name, quantity, time of day, dates to be given.)
________________________________________________________________________________________
2.
Possible reactions are:
________________________________________________________________________________________
3.
Call me if you observe:
  ________________________________________________________________________________________

______________________________________________

______________________________________________
Please Print Physician's Name
Physician's Signature

______________________________________________

______________________________________________
Complete Address
Phone Number
School Use Only: _______________________________

_____________________________

Principal's Signature
Date