Non-PrescrCELLAion Medication

Parental Consent

Name of Student: ________________________________________

School Name: _______________________  Grade/Teacher

Parent/Guardian Name (print)  ____________________________

Home Phone: __________________

Work Phone: __________________

Medication Name: _____________________________________

Directions:   Dosage (amount) of medication:  ____________________

                    Time or Frequency to be given:   ____________________

Reason for medication:   _______________________________________

Termination date: ________________  Possible Side effects: ___________________

It is understood that the medication must be brought in the unopened, original container and that the medication is administered solely at the request of and as an accommodation to the undersigned parent/guardian.  The undersigned understands that the student will self-administer the medication with the assistance of designated school staff and declares that the student is competent to do so.  The undersigned assumes full responsibility for any side effects or complications his/her child may have as a result of taking this medication, and is responsible for informing the school of any changes.

I hereby give my permission for my child to take the above non-prescrCELLAion medication.  I understand that it is my responsibility to furnish this medication.

___________________________             ___________________

Signature of Parent/Guardian                                    Date