Authorization for Prescription Medication

Student First Name *

Student Last Name *

Name of School Student attending: *

Diagnosis
(Type N/A, if not applicable)

+-

Medication & Dosage Prescribed
(Type N/A if not applicable)

+-

Instructions for Administering Prescription Medicine

(Medicine must be provided in a pharmacy container indicating the student's name as well as complete instructions for dispensing. Prescribing labels that state, "Take as Directed" will NOT be accepted.)

Instructions:
(Type N/A if not applicable) *

Side Effects of Prescription Medicine:
(Type N/A if not applicable) *

Physician's Name: *

Phone: *

Parental Permission (to be signed & completed by Parent/Legal Guardian):

I grant the Health Care Manager or his/her designated chaperone permission of our student's school to assist in the administration of each prescribed medication to be provided.

I hereby release and hold Nord Anglia Education and its affiliated companies and schools and their respective officers, employees, agents and represenatives harmless from any liability for administering these prescription medications.

Parent/Guardian Full Name: *

Parent Email: *

Parent/Guardian Phone Number: *

Signature of Parent/Legal Guardian *

clear

Date of Signature: * +