St_Joseph_Toledo_letterheadText Box: ST. JOSEPH SCHOOL REQUEST FOR ADMINISTRATION OF MEDICATION OVER THE COUNTER AND PRESRIPTION Student:___________________________Date:_________________________ Address:___________________________Telephone:____________________ School Teacher:_____________________ Physician’s Instructions for Administering Medication: Administration of this medication during school hours is necessary for this child’s attendance at school. THIS INCLUDES INHALERS Name/Type of medication: ___________________________________________ Dosage/amount to be given: ___________________________________________ Frequency/Times to be administered: ______________________________________ Duration: ______________________________________________________ Physician’s Signature:____________________________________________ Telephone Number:______________________________________________ Parent/Guardian Authorization: We hereby request that the above medication and procedure as outlined by our physician be administered to our child. We understand that the Catholic District School Board of Eastern Ontario will not be legally responsible for the administration of the medication. Parents Instructions for OVER THE COUNTER medicine (provided by the parent): ______________________________________________________________________ ______________________________________________________________________ Parent/Guardian Authorization: We hereby request that the above over the counter medication can be administered to our child. We understand that the Catholic District School Board of Eastern Ontario will not be legally responsible for the administration of the medication. Parent/Guardian Signature______________________________________________ If your child carries an inhaler on their person please fill this out so we can keep this on file for emergencies. Name:__________________________ Type of Inhaler:______________________ Note: This request will expire June 30 of each school year or at the end of the duration as specified above.