Contract for self-carried medication

Contract for Self-Carried Medication
Student Name*

First NameLast Name
Grade*
Physician's Name*

First NameLast Name
Physician's Phone Number*
Please enter a valid phone number.
Medication*
Dosage*
Medication is permitted in accord with district policy. The student's physician must authorize self-carried/administered medication. Student name must appear on medication(Inhaler, container).
Parent/Guardian permission*

I give permission for the exchange of information(verbal, written, faxed) between the above named health care provider and sugar creek charter high school nurse as needed. I understand that this information will remain confidential.I request that my child be allowed to carry his/her medication and be responsible for it's proper storage and use. I will support my child to follow the above agreement and if she/he doesn't, i will be contacted and we will develop a new plan.
Signature
Date
Should be Empty:

Contract for Self-Carried Medication