Child’s Name (First & Last): _______________________________________

Home Phone: ____________________ Cell: _________________ Work Phone: ___________________

School: _________________________________            Teacher: ______________________________

 Having read the policy below, I hereby request that all over the counter and prescriptive medication be stored and dispensed by the school nurse or her assistant, to my child while at Camp Cispus. And further, I will hold the school district and school personnel harmless from any liabilities that might result from dispensing of medication or lack of dispensing of medication.

Date: _______________________ Parent/Guardian Name: __________________________________

Parent/Guardian Signature: ____________________________________________________________

Medication to Be Administered:___________________________________________________________

Purpose of Medication:________________________________________________________________

Dosage and Mode of Administration: _____________________________________________________

Time to Be Administered: ______________________________________________________________

Possible Side Effects of Drug(s): _________________________________________________________

What observable effects do you wish us to report? ___________________________________________

___________________________________________________________________________________

Parent Permission for Student to Carry Asthma Inhaler:   Yes__________            No__________

Date: ____________________ Physician’s Name: ___________________________________________

Physician Phone Number: ________________ Physician Signature: _____________________________

 Prescription medication may be stored and dispensed to students but not without parent’s request/signature and physician’s authorization (3416F). Prescription medication to be stored and dispensed must be in a prescription original labeled container. All procedures that may be necessary will be in accordance with state law and school board policies.

 Parents are responsible to send a 3-day supply (only) of medication for camp.

**Medications must be turned in to the school nurse the week of Mar 26-Mar 30, 2018!

 Please send medication in the original container with child’s name, RX, dosage and time to be given. School personnel will store and distribute medication to students whose parents and physician have given written consent. Medication shall be administered by injection by school personnel only under life-threatening conditions as per board policy.

Updated 11/20/2018 Pink