Note to parent/guardians:

Note to Parent/Guardians:
To comply with State Law governing the administration of medication at school, the Pendleton County
School system requires that all students who need medication during school hours do the following:
1. The parent or legal guardian must sign the written consent form for both non-prescription and prescription
medication. (The school does not provide non-prescription medication, such as Tylenol, Benadryl, etc. It is the
parent’s responsibility to send this medication to the school in the original container.)
2. The Prescription medication section of this form must be signed by the physician, and the prescription
medication sent to school in the original prescription bottle.
3. A medication form is required for each medication.
4. If there is any question about the dosage of medication the child is to receive, it will not be given unless the
parent or physician clarifies instructions.
5. The first dose of any medication must be given at home due to the possibility of allergic reaction.
6. Medication should only be taken at school when absolutely necessary; it is best to give medications at home.
Name of Student_____________________________________ Date of Birth ___________________________
Age______________ Grade_________________ School ___________________________________________
I, ____________________________ hereby request that trained, authorized staff of the Pendleton County Board of Education administer the non-prescription medication listed below to my son/daughter as directed by the physician. ____________________________________________ ____________________ ______________________ PARENT/GUARDIAN SIGNATURE TELEPHONE DATE
(For medication such as Tylenol, Advil, Benadryl, etc.) (Completed by Parent)
Name of medication:_________________________________________________________________________ Reason for Medication (illness): _______________________________________________________________ Dosage ________________________ Time to be given: ____________________________________________ Comments: ________________________________________________________________________________ PRESCRIPTION MEDICATION
(Physician Signature Required)
Name of Medication: ________________________________________________________________________
Reason for Medication: ______________________________________________________________________
Specific time(s) and dose(s) to be given at school: _________________________________________________
Method of Administration: _______oral _______IM injection_____subq. Injection______inhalation_____other
Comments: (side effects, and/or other instructions) ________________________________________________
________________________________________ __________________________________ _____________
Printed Name of Physician Signature of Physician Date


Friends Life Protection Account Asthma, Bronchitis, other respiratory disorders Questionnaire Important Notes: • The information given in this questionnaire is confidential when completed • Please give a full and complete answer to each of the following questions, continuing your answers on a separate sheet of paper if there is insufficient space • Please fill in this q

Fruit juices and elixirs

Café Gratitude is our expression of a world of plenty. Our food and people are a celebration of our aliveness. We select the finest organic ingredients to honor the earth and ourselves, as we are one and the same. We support local farmers, sustainable agriculture, and environmentally-friendly products. Our food is prepared with love. We invite you to step ins

Copyright © 2018 Medical Abstracts