BETHEL PARK SCHOOL DISTRICTBethel Park, Penasylvania

R-EQT.IEST FoR. AD TI"USTRATION oF MEDICATIOND{jRING SCHOOL HOTiRS

The Bethel Park school District requests that medication bc givca at home dunog sog-school bours- 6owcvcr, itr€cogE:es that ssmefi"ncs it i* esscatial formedircatioa to !6 adrninislcrcd af schoo!- No "over-the-cormter" medicatioa?7ii1 bc gvaa io ally studeni witLout an ord'er froa a physiciaa, alongvith sigaatures from the physiciaa z.ad parent(s).'aji raqiication MUST be is a Pbafiaacr lab€lcd cou.taiacr- The labei nust iaclude the aaac a:ed phoae -'.n!61of thc-cira:=racy, thcpupil's rta.EBe, thc physician's Ea.Ee, thcmcdicatio4 theorrentl-v prcscribed dosc, rimg sfartministratio-aeg ftc P; nrm.ircns

Mc<iicatioa datc<i reithiE thc iast two wecks asd to sg zH'niEislsrcd. No MoRE TIIAN 10 scHool Da-l's rcgairesa paieat's/guardiaa's sis.aturc aad the complction of the inforsatioa bclow-fr{criisatioa prcscribcd for loagcr ti"?n a two-r*k pcriod also rcqu:res tle prescriblag pbysician,s sigsaturs-

STIjDE}.IT'S NAME LtsST FIRST GR.A-DE AGE

PIIYSICIAN"S NAME (print) PHONE

r::-ders!e'ad fully tlre directioa-s ti'at have becu given to the school by the ph5rsrciaa aad agre to prait ile sbool;s 2'{-ni:li5tr tlis medicatioa to my child- rr coasidcration of tie school district's agrecr,rear ro us good faiti efforts"o

pio=cil;- ad:eiaister rhis mecica'cca, thedis*ct ishereby reiievcd from liabiiityfora-ayfailurc io propcriy pr{-.:hi5i3;L2i'ai sa'rcc- I aiso authonze the school to'co!.tact said phisician rega-rding this mcdicatioa-

DATE PARENT/GUARDIAN SIGNATURE ITOME PHONE WORK PTIONE

c.i tiedici-D.e:

;i Diagsosis{Reasoa medica.ticn is prescribed):

Route:

if -.eCicire is to bc gi"ea 'TV-IIEN NEEDED-"desc-* iadi=tiors:

ti

irow soo-rr-c:., it bc repatcti?

Lisi signiiica-lt sids effects:

ixagtb of tit g this treatsest is rscor.i".eaCcd:

Lia--ijciec io be givca DAILY, "1o62i

tirne?

Ciier i:fo;a.atios:

Da!.c Physicia.'s si grat.ui-e

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