PARENTS ORDER FOR NON-DRUG MEDICATION

SCHOOL _________________________________ SCHOOL YEAR _______________

NAME

____________________________ Last

______________________ First

____________ Middle

Age _______ Weight _______ Height ________ D.O. B.________

1.	____________________ Medication	_____________________ Amount	_____________ Time given
2.	____________________ Medication	_____________________ Amount	_____________ Time given
3.	____________________ Medication	_____________________ Amount	_____________ Time given

______________________________________________________________ Special instructions for dispensing, storage, etc.

______________________________________________________________

______________________________________________________________ Behavior or symptom teacher is to report change in

Parent phone     Home ___________________ Work ___________________

Parent/Guardian Signature ____________________________________________

Name of Parent or Guardian

_______________________________________ PLEASE PRINT IN ENGLISH

Parent/Guardian E-Mail __________________________________________