Physician'S School Medication Form
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1Rev. 8/12
CUMBERLAND COUNTY SCHOOLS
PHYSICIAN’S SCHOOL MEDICATION FORM
Name of School:
Name of Student:
Grade:
Age:
The above named person is a patient currently under my medical care. Due to a medical condition the
medication listed below needs to be (given / taken / injected) during regular school day according to the
following protocol:
Medication:
Dose:
Route:
Routine/Daily Medications: Time to be given
a.m.
p.m.
As needed medication for
Give every
hours.
Directions for administering medication:
If an emergency situation occurs during the school day, or if the pupil becomes ill, school officials are
to:
a) Contact me at my office:
b) Take child immediately to the emergency room at:
c) Other option:
This medication will be properly labeled and will carry my name as the prescribing physician.
Physician’s Signature
Date
RELEASE OF LIABILITY FORM
I,
the parent and/or legal guardian of
enrolled at
Name of Child
Name of School
Realizing the importance of administering medication to my child as prescribed by the child’s physician, do
hereby agree to relieve designated school personnel of any liability from any potential ill effects as a result of
their injecting or giving my child medication prescribed by the child’s physician. I have discussed this with my
physician and/or legal counsel (lawyer) and realize its ramifications and thoroughly understand the meanings of
these statements. I consent for the medical provider to disclose health or medical information regarding
medication prescribed. I understand that I may revoke this consent at any time, except to the extent action has
/
/
.
been taken in reliance on it. This consent is valid until I revoke it in writing for the term of one year
Parent or Guardian’s Signature
Date
Principal’s Signature
Date
FOR SCHOOL USE ONLY
Date Physician School Medication Form Expires:
/
/
.
Please be reminded form will expire one (1) year from date of physician’s signature.
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