Editing previous response:

Please fix the highlighted areas below before submitting.

Permission to Administer Prescription/OTC Medication

school logo

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

** Please note that staff/faculty are only authorized to dispense medicine brought in by the parent, even over-the-counter medicine. By completing this form, you agree to bring the medicine to the school, where it will be stored in a secure location for use only by the student for whom it was intended.

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

Answer required for "My permission is herby granted to Jewish Academy of Orlando personnel to administer prescribed medication to: "

Student Date of Birth*

Answer required for "Student Date of Birth"

Name of prescription/OTC medication:*

Answer required for "Name of prescription/OTC medication:"

Name of prescribing physician*

Answer required for "Name of prescribing physician"

Directions for administering:*

Answer required for "Directions for administering:"

Amount to be given/dosage:*

Answer required for "Amount to be given/dosage:"

Times to be given medication:*

Answer required for "Times to be given medication:"

Date to begin:*

Answer required for "Date to begin:"

Date to stop:*

Answer required for "Date to stop:"

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

Answer required for "Explain the necessity for the prescribed medication to be provided during the school day."

Is this a rescue medication?*

Answer required for "Is this a rescue medication?"

Yes

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

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

Choose a file or drag it here.

Submitted by:

Parent Name

Answer required for "Submitted by: "

Submission date:*

Answer required for "Submission date:"

* 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*

Answer required for "I understand and agree"

Yes

Confirmation Email

Confirmation Email *

Answer required for "Confirmation Email"