Release For The Administration of Medication Form

Release For The Administration of Medication Form

Student Information

Parent Information

Physician Information

Medication Information

We, the undersigned, request that a member of the school staff administer to our child the medication prescribed according to the instructions given to us, by our physician.
We will file any new medication instructions immediately if the medication or dosage is changed.
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Therefore the above medication cannot be scheduled for other than during school hours and such medication maybe administered by medically untrained school personnel whenever necessary.
Sending
Prince of Peace School | 1421 W. Ball Rd. Anaheim, California 92802 | 714-774-0993