Medication Dispensing Release at School

Name
First Last
This is to authorize and direct Miriam Academy staff to give my child medication at school. I certify that such medication has been prescribed for my child by his/her doctor and I give permission for sufficient amounts of this medication to be kept at school and dispensed to my child, as directed, during the school day.
Medication at School*
- Yes
- No
School Medication 1
# of tablets, etc.
Time administered
Directions
School Medication 2
Dosage
# of tablets, etc.
Time administered
Directions
School Medication 3
Dosage
# of tablets, etc.
Time administered
Directions
School Medication 4
Dosage
# of tablets, etc.
Time administered
Directions
School Medication 5
Dosage
# of tablets, etc.
Time administered
Directions
School Medication 6
Dosage
# of tablets, etc.
Time administered
Directions
School Medication 7
Dosage
# of tablets, etc.
Time administered
Directions
Parent / Guardian Signature*
First Last
Date*
Date Format: MM slash DD slash YYYY
Pin Number*
CAPTCHA