ERVING SCHOOL UNION #28
18 PLEASANT STREET
ERVING, LEVERETT, NEW SALEM, WENDELL, SHUTESBURY
ERVING, MA 01344
FAX 413 423-3236
PARENT/GUARDIAN CONSENT FOR MEDICATION ADMINISTRATION
Name of Student_______________________________________
Date of Birth_________________ Sex ______
Name of Parent/Guardian______________________________Address_________________________________
Other person to be notified in case of emergency if parent/guardian is unavailable:
My son/daughter is currently receiving the following medications (to be completed if not in violation of confidentiality):
1 ____________________ 2 _____________________ 3 ____________________
My son/daughter is known to have the following allergies______________________________________________
I give permission to have the school nurse, or school personnel designated by the school, to give the following medicine_______________________________________ (name of medicine)
prescribed by______________________________ (licensed prescriber) to
____________________________ (name of student) at _______________ (time) for the following
period_________________________ (beginning date to ending date).
A before school dose will be given at _____________________________. (time before school)
I give permission to the school nurse to share with appropriate school district personnel information relative to the prescribed medicine administration, e.g., adverse side effects, as she/he determines necessary for my sonʼs/daughterʼs health and safety.
YES ______ NO ______ Any restrictions on release ______________________________
Please note, I understand that I may retrieve the medicine from the school at any time and that the medicine will be destroyed if it is not picked up within one week following the termination of the order or one week beyond the close of school.
Signature of Parent/Guardian __________________________________________________________________
Relationship to Student: _______________________Date: ______________________
Erving School Union #28 assures that all programs, activities and employment opportunities are offered without regard to race, color, sex, age, creed, homelessness, religion, national origin, sexual orientation and disability.