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River Vale Schools
River Vale, NJ
Authorization For Administration of Medication
The following section is to be completed by the PARENT:
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Child's name________________
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Date of birth_________
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School________________
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Grade____
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I request that my child be administered or assisted in taking the medication
described below at school by authorized persons. I relieve the Board of
Education and its employees of any and all liability which may result
from the administration of this medication to my child.
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______
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_________________
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(____) _____________
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(_____)_____________
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Date
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Parent/Guardian Signature
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Home Phone
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Emergency Phone
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_________________________________________________________________________________________________________
The following section is to be completed by the PHYSICIAN:
| Diagnosis for which the medication is prescribed_____________________________________________________________ |
| Name of the medication _________________________________________________________________________________ |
| Dosage ______________________________________________________________________________________________ |
| Time ________________________________________________________________________________________________ |
| Can medication be repeated and how soon
_________________________________________________________________ |
| List significant side effects
_______________________________________________________________________________ |
| Length of time that medication may be needed_______________________________________________________________ |
| Allergies or other significant information
____________________________________________________________________ |
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