BMS MEDICATION ADMINISTRATION CONSENT FORM
This form is good for the 2020-21 school year and must be updated anytime the student's medication order changes and it must be renewed each year and/or anytime a student changes schools.
Medications, including those for self-administration, must be in the original container and be properly labeled with the student's name, the ordering provider's name, the name of the medication, the dosage, frequency, and instructions for the administration of the medication (including times).  Additional information accompanying the medication shall state the purpose for the medication, it's possible side effects, and any other pertinent instructions (such as special storage requirements) or warnings.
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Student's full name *
Student's grade *
Parent's full name *
Parent's phone number *
By typing your name (parent or legal guardian) below, you authorize the school nurse or his/her designee to administer the following medications to your child. *
Name of medication(s)
Name of physician or dentist (if applicable)
What is the dosage for the medications
Instructions for administering the medication
Please check any of the over-the-counter medications listed below that we are allowed to administer to your child while they are at school.
Please type your name (parent or legal guardian) below to verify your understanding - I acknowledge that the District, its Board of Directors, and its employees shall be immune from civil liability for damages resulting from the administration of medications in accordance with this consent form. *
Date *
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