Date: ________________________

Child's Name: __________________________________________  has been instructed in the proper

use of the following medication procedures:

__________________________________________________________________________________

__________________________________________________________________________________

Physician's Signature: ___________________________________________________  and 

Parent or Guardian signature: ___________________________________________________________ 

Request that (Child's Name) ______________________________________________  be permitted

to carry the medication on his/her person or to keep same in his/her locker or PE locker, as we 

consider him/her responsible. He/she has been instructed in and understands the purpose and 

appropriate method and frequency of use.

Note: This form must be completed in addition to routine district medication for those students who 

request permission to carry their own medication on campus or keep this medication in PE locker. 

Nurse's Fax number - 845-351-3402