Medical Form

EASTERN SCHOOL DISTRICT AUTHORIZATION FOR ADMINISTRATION OF MEDICATION Form 1-B

STUDENT’S NAME: _____________________________		MCP #: ________________________

PHYSICIAN’S STATEMENT:
	I hereby certify that the above named student has a chronic medical condition which makes him/her unable to attend school safely unless he/she receives the following medication. I also certify that administration of this medication DURING SCHOOL HOURS is necessary for this child’s attendance at school.

TO MY KNOWLEDGE, THERE ARE NO TREATMENT REGIMENS FOR HIS/HER CONDITION THAT CAN BE GIVEN OUTSIDE THE SCHOOL HOURS.

a) Name/type of medication:
______________________________________________________________________

b) Dosage/amount to be given:
______________________________________________________________________

c) Method of administration:
______________________________________________________________________

d) Frequency/times to be administered:
______________________________________________________________________

e) Duration:
______________________________________________________________________

f) Type of storage required for medication:
______________________________________________________________________

g) Anticipated reaction to medication (symptoms, side effects, etc):
______________________________________________________________________

h) Other: (Be specific)
______________________________________________________________________



_________________________		_________________________
Physician’s Signature		Date Signed

_________________________		_________________________
Physician’s Address		Telephone Number

NOTE: A new authorization form must be submitted each school year and whenever the medication is modified.

C.c. Parent/Physician/Principal