Delphos City Schools

Parent's Instructions for administering Non-Prescription Drugs at School

1. Student's Name___________________________________________________________________

2. Student's Address_________________________________________________________________

3. School__________________________________________

  4. Class_____________________________

5. Name of Drug___________________________________________________________________

6. Dosage of

7. Time of Intervals Dosage of Drug is to be Administered________________________________________________________________________________________________________________________________________________________________

8. Date Administration of Drug is to begin____________________________________________________________

9. Date Administration of Drug is to Cease___________________________________________________________

10. Severe Adverse Reactions that should be reported to a Physician_____________________________________________________________________________________________________________________________________________________________________________________________________________________________

11. Physician Name and Emergency Telephone Number_________________________________________________________________________________________________________________________________________

12. Special Instructions for Administration of the Drug, Including Sterile Conditions and Storage______________________________________________________________________________________________________________

13. Other Medication or Drugs Student is Taking__________________________________________________________________________________________________________________________________________

           ________ My child has permission to administer his or her own medication

           ________  I wish for the school to administer the medication to my child.

________________________                                   _____________________________

                                                                Date                                                                        Physician's Signature