School Medication Form

Family Name:

Phone

Address:

Email (Mother)

Email (Father)

Student Name:

Date of Birth:

Grade

IN CASE OF EMERGENCY, ILLNESS, OR ACCIDENT TO THE CHILD NAMED ABOVE, THE SCHOOL IS AUTHORIZED TO PROCEED AS INDICATED BELOW (NUMBER EACH ITEM IN ORDER OF DESIRED ACTION). YOUR CELL NUMBER COULD SAVE A LIFE.

Contact

Mother‎ Father‎

Mother's Phone

Father's Phone

Physician's Name:

Physician's Phone #:

Physician's Address

Medication Name:

Condition for which the drug is administered:

Instructions for Medication Administration:

By checking this box, you are giving Yeshiva Derech HaTorah permission to administer Acetaminophen to your child.

ALLERGIES, PHYSICAL LIMITATIONS, OR MEDCAL INFORMATION SCHOOL SHOULD BE AWARE OF:

Parent/Guardian Authorization Signature:

Clear

Consent is hereby given to allow my child to go by vehicle or otherwise on trips away from school, and the school will provide supervision for such occasion.

Date