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PARENTAL REQUEST AND PHYSICIAN S ORDER FOR MEDICATION For use in requesting the school s service when medication must be given during the school day by the school medication designee TO BE COMPLETED BY PARENT/GUARDIAN Child s Name Date School I request that my child named above be given the medication as indicated in the physician s order below. I am aware that non-medical personnel will be administering this medication to my child. I hereby release the Catawba County Schools their agents and their employees from any and all liability that may result from my child taking the prescribed medication. Parent/Guardian Signature Telephone day in order for the student to maintain his/her authorized medication plan Name and Form of Medication Dosage Times to Be Given Route of Administration Other Specific Directions Purpose of Medication Side Effects to Watch For Duration of Order Physician s Name and Address Please Type and/or Print Physician s Signature Thank you for completing this form. Telephone Number. PARENTAL REQUEST AND PHYSICIAN S ORDER FOR MEDICATION For use in requesting the school s service when medication must be given during the school day by the school medication designee TO BE COMPLETED BY PARENT/GUARDIAN Child s Name Date School I request that my child named above be given the medication as indicated in the physician s order below. I am aware that non-medical personnel will be administering this medication to my child. I hereby release the Catawba County Schools their agents and their employees from any and all liability that may result from my child taking the prescribed medication* Parent/Guardian Signature Telephone day in order for the student to maintain his/her authorized medication plan Name and Form of Medication Dosage Times to Be Given Route of Administration Other Specific Directions Purpose of Medication Side Effects to Watch For Duration of Order Physician s Name and Address Please Type and/or Print Physician s Signature Thank you for completing this form* Telephone Number.

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