St. Ephrem School

DIRECTIONS FOR ADMINISTERING PRESCRIBED MEDICATION

School Year  ___________________

Student’s Name  ______________________________________________  Grade ___________

Name of Parents/Guardians  ______________________________________________________

Medicine Prescribed  ____________________________________________________________

Condition for which medicine is prescribed  __________________________________________

______________________________________________________________________________

______________________________________________________________________________

Dosage:  ______________________________________________________

Directions for Administering Medication  ____________________________________________

______________________________________________________________________________

Possible side effects:  ____________________________________________________________

Name of Physician  ________________________________________________________  

Date ___________________                                      Phone #  _______________________

Physician’s Signature  ___________________________________________________________

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Parental Consent         

            I give permission for the school nurse or designate to give my child,

__________________________________________________,  the above medication.

_______________________________________________              _________________

                        Parent Signature                                                                       Date