AUTHORIZATION TO GIVE MEDICINE

AUGUST 2007 – AUGUST 2008

I hereby request the personnel of St. Gabriel Child Care to give medicine to my child,

__________________________________________________________. This medicine has been prescribed for my child by

Dr. ___________________________________________________, whose address is _________________________________________________.

These instructions should be followed in giving my child this medicine:

1. Type of medicine________________________________________________________________________________________

2. Dosage____________________________________________________________________________________________________

3. Time of day for dosage________________________________________________________________________________

4. Reason medication is to be given___________________________________________________________________

5. Reactions or side effects (please list potential reactions the child might have to medication)

______________________________________________________________________________________________________________

______________________________________________________________________________________________________________

6. Physician’s telephone number_______________________________________________________________________

7. Parents’ telephone numbers: Mother Father

Home ________________________________ ________________________________

Work ________________________________ ________________________________

Emergency ________________________________ ________________________________

Signature of Parent or Guardian_________________________________________________________________________

Signing this form shall release St. Gabriel Child Care, St. Gabriel the Archangel Parish, St. Gabriel School System and staff members from any liability of any nature that might result from the administration of medication to the student.