File:  JLCD-E - Permission for Medication

Name of student _______________________________________

School __________________________ Grade _______________

Teacher ______________________________________________

Medication _______________________ Dosage ______________

Purpose of medication ____________________________________

_____________________________________________________

Time of day medication is to be given _________________________

Possible side effects ______________________________________

______________________________________________________

Anticipated number of days it needs to be given at school __________

______________________________________________________

Date ______________  ___________________________________

                                                                Signature of physician

It is understood that the medication is administered solely at the request of and as an accommodation to the undersigned parent or guardian.  In consideration of the acceptance of the request to perform this service by the school nurse or other designee employed by the Cheraw School District, the undersigned parent or guardian hereby agrees to release the Cheraw School District

and its personnel from any legal claim which they now have or may hereafter have arising out of the administration of or failure to administer the medication to the student.

I hereby give my permission for __________(name of student)__________ to take the above prescription at school as ordered.  I understand that it is my responsibility to furnish this medication.

Date ______________  ___________________________________

                                                        Signature of parent or guardian

NOTE:  The prescription medication is to be brought to school in a container appropriately labeled by the pharmacy or physician stating the name of the medication and the dosage.