MEDICATION PERMISSION REQUEST FORM When possible

PRINCIPAL
Ann Marie Garza
ASSISTANT PRINCIPAL
Cynthia Vasquez
MEDICATION PERMISSION REQUEST FORM
When possible, students should take medications before coming to school and/or after leaving school.
Medicine given at school should only be necessary if instructions require four or more doses per day,
or if there is a doctor’s order requiring medicine to be given at a specific time during the school day.
The medicine must be in the original container for the specific student and include the following
information: current date, student’s name, specific instructions (dosage & time), name of medicine,
and doctor’s name. Refer to the “Student Handbook” for further information.
Name of Student__________________________________ Date of Birth__________ Grade_____
Teacher__________________
Tanya Lee Merka, RN
Telephone #: 281-452-2880
Fax #: 281-452-3709
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To Be Completed by Physician
Condition Requiring Medication____________________________________________________
Name of medication_____________________________________________________________
Specific time(s) and dose(s) to be given at school______________________________________
Start Date: _____/_____/_____
End Date: ______/_____/_____
Are there any restrictions? ___ ___ If yes, what and how long?__________________________
Yes No
_____________________________________________________________________________
______________________ _____________________
Printed Name of Physician
Signature of Physician
_______________ ______________
Phone #
Fax #
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To Be Completed By Parent
I give permission for my child, _________________________, to receive the above medication as directed.
__________ ____________________________
Date
Parent/Guardian Signature
_____________________________
Printed Name of Parent/Guardian
Daytime Telephone #_______________________
The Channelview Independent School District does not discriminate on the basis of race, religion, color, national origin, gender, sex,age or disability in providing education services, activities, and programs, including
vocational programs, in accordance with Title VI of the Civil Rights Act of 1964, as amended; Title IX of the Educational Ame ndments of 1972; and Section 504 of the Rehabilitation Act of 1973, as amended. The district Title
IX Coordinator is Assistant Superintendent of Administration, MikeNeimyer.
El Distrito Escolar Independiente de Channelview no discrimina por motivos de raza, religión, color, origen nacional, género , sexo,edad o discapacidad en la prestación de servicios de educación, actividades y programas,
incluyendo programas vocacionales, de acuerdo con el Título VI de los Derechos Civiles la Ley de 1964, según enmienda, Titulo IX de las Enmiendas Educativas de 1972, y la Sección 504 de la Ley de Rehabilitación de
1973, según enmendada. El Coordinador del distrito del Titulo IX es el Asistente Superintendente de Administracion, Mike Neimyer.
The Channelview Independent School District does not discriminate on the basis of race, religion, color, national origin, gender, sex,age or disability in providing education services, activities, and programs, including
vocational programs, in accordance with Title VI of the Civil Rights Act of 1964, as amended; Title IX of the Educational Ame ndments of 1972; and Section 504 of the Rehabilitation Act of 1973, as amended. The district Title
IX Coordinator is Assistant Superintendent of Administration, MikeNeimyer.
El Distrito Escolar Independiente de Channelview no discrimina por motivos de raza, religión, color, origen nacional, género , sexo,edad o discapacidad en la prestación de servicios de educación, actividades y programas,
incluyendo programas vocacionales, de acuerdo con el Título VI de los Derechos Civiles la Ley de 1964, según enmienda, Titulo IX de las Enmiendas Educativas de 1972, y la Sección 504 de la Ley de Rehabilitación de
1973, según enmendada. El Coordinador del distrito del Titulo IX es el Asistente Superintendente de Administracion, Mike Neimyer.