Supervising Medications Form

Student First Name

Student Last Name

Select

Male

Female

Grade

Name of Medication

Purpose of Medication

Possible Side Effects

Dosage

Times to Administer Medication

End Date

Other information or comments:

Primary Parent/Guardian First and Last Name

Primary Parent/Guardian Email

Primary Parent/Guardian Phone

Second Parent/Guardian First and Last Name

Second Parent/Guardian Email

Second Parent/Guardian Phone

By checking this box, I acknowledge and agree...

I give permission to the staff of Pilgrim Lutheran Church and School to administer and supervise use of this medication.
For prescriptions, the physician or pharmacist is requested to provide a duplicate bottle of the medication, which shall include the name and telephone number of the pharmacy, the child’s name, the name of the physician, and the dosage of the medication to be given.
I release the Pilgrim Lutheran Church and School and staff from liability, should an adverse reaction result from the medication.

Type Name (Serves as Signature)

Today's Date