SOMERSET HILLS SCHOOL DISTRICT
_______________________________________________________________
Bernardsville, New Jersey 07924

MEDICATION ADMINISTRATION REQUEST

Student's Name____________________________________Grade/Homeroom________

Home phone number_______________________________

TO BE FILLED OUT BY PHYSICIAN:

Please administer the following medication to the above named student as prescribed below:

Medication/ Dose______________________________________________________________

Reason for Medication__________________________________________________________

Time to be Administered_________________________________________________________

To be given from (date)______________________________Stop Date____________________

Side Effects to be reported_______________________________________________________

Medication for non-life threatening conditions will NOT be administered on field trips unless medically required by a physician.

On field trips, medication is________ is not_________ required.
On half days, medication is ________ is not ________ required.

Physician's Name

(printed)_____________________________________________Phone_____________________

Physician's Signature_____________________________________________________________

TO BE SIGNED BY PARENT/GUARDIAN:

I give my permission for the above medication to be administered to my child at school. I realize that any changes or modifications of this order will require a written authorization from this physician.

Parent/ Guardian's Signature______________________________________________Date______________