AUTHORIZATION TO ASSIST COMPETENT STUDENT WITH SELF-ADMINISTRATION OF MEDICATION
Medication shall be administered only when the student's health requires that it be given during school hours.  It is the parent/guardian's responsibility to bring this medication to school and remove any unused medication when treatment is completed.
All prescription medication must be brought to school in the original container. The pharmacy label must include the following information:
  • Name of student
  • Prescription Number
  • Name of medication and dosage
  • Administration route or other directions
  • Date
  • Licensed prescriber's name
  • Pharmacy name, address and phone number                      
All non-prescription medication must be brought to school in the original manufacturer's labeled container with the ingredients listed and the child's name affixed to the container. No more than one month's supply of any medication should be brought to school.

HOPEWELL ~ PARENT/GUARDIAN AUTHORIZATION
Student Name   ___________________________________________________________                                 
Date____________________________________________________________________
I request that school personnel assist the above named student to self-administer the following the medication while in school and away from school for school activities.

Name of Medication___________________________

Amount of medication to be taken______________________
How medication is to be taken (orally, topically, inhalation, injection): ________________    Time(s) medication is to be taken:___________________

Date last dose of this medication is to be taken ____________                                              Reason medication is needed at school: __________________________________

Signature of Physician (if required by the principal) _______________________________      Date: ____/_____/_____ 
It is understood that the medication is administered solely at the request of and an an accommodation to the undersigned parent or guardian. In consideration of the acceptance of the request to perform this service by any person employed by Bradley County School System, the undersigned parent/guardian hereby agrees to release Bradley County School System and its personnel from any legal claim they now have or, may thereafter have, arising out of the administration of or failure to administer the medication to the student. I will assume full responsibility for any side effects and complications that my child may have as a result of taking this medication.
Parent/Guardian Signature____________________________________________________  Date ___/____/____
Print Parent/Guardian Name __________________________________________________
Home Phone_______________________work#___________________cell #__________________