LONG TERM AUTHORIZATION FOR MEDICATION DURING SCHOOL HOURS

TO:     

                                   (Full Name of Teacher)

                                                                   must receive the following prescribed medication

                       (Name of Student)

during school hours in order to maintain sufficient health to participate in the school program.

           Name of Medication:  

           Prescribed Dosage:   

           Time Schedule:          

           Length of Time:                       Days                Months

                                                                                   Indefinitely

           Diagnosis:                  

           Reason for Administration:

           Possible Side Effects:            

           I do hereby release, discharge, and hold harmless Champion Christian School, its agents and employees, from any and all liability and claim whatsoever for the administration of the above medication to my child should there develop a reaction from the medication.

/

                                               (Signature of Physician)          (Date)

/

                                          (Signature of Parent / Guardian)               (Date)

082099