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Permission to Administer Prescription/OTC Medication

Please complete the form below. Required fields marked with an asterisk *

My permission is herby granted to Jewish Academy of Orlando personnel to administer prescribed medication to: *

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Student Date of Birth*

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Name of prescription/OTC medication:*

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Name of prescribing physician*

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Directions for administering:*

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Amount to be given/dosage:*

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Times to be given medication:*

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Date to begin:*

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Date to stop:*

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Explain the necessity for the prescribed medication to be provided during the school day.*

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Is this a rescue medication?*

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Yes

If it is a rescue medication, please upload the plan of care from your prescribing physician.

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Choose a file or drag it here.

Submitted by:

Parent Name

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Submission date:*

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* It is hereby understood by the undersigned that school personnel are not held liable for the administration of the above medication or for its possible side effects.

** Medication is to be brought in its original pharmacy container. Duplicate containers can usually be obtained from the pharmacist for home storage if needed. For safety and security reasons, it is mandatory that all medications be brought to school by the parent/guardian, and not sent in with the child. If the medication is sent in with the child it will not be administered.

I understand and agree*

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Yes

Confirmation Email

Confirmation Email *

Email Required