May 2011 Dear Parents: It is hard to believe that this school year is ...

Authorization to Administer Medication
2010-2011
School Year
Hudsonville Christian School requires written parent authorization for prescription medication to be taken by students in school.
This form must be on file at school if your child is to take medicine at school, whether administered by the teacher or taken by the
student without the teacher’s help. Medication must be kept in containers with the original pharmacy label.
Student_______________________________________________________
Grade___________________ Teacher______________________________
Student’s physician______________________________________________
Physician’s phone number________________________________________
Hudsonville Christian School has permission to administer medication to my child, named above, according to the
following schedule and dosage for the current school year (2010-2011).
Name of medicine:______________________________________________
Amount of dosage (in milligrams or other):___________________________
Time(s) of the school day to administer:_____________________________
Comments:
Administration of medication at Hudsonville Christian School must be preceded by filing a dated and signed authorization form. I
understand that any change in medical treatment (type of medication, dosage or frequency) cannot occur until an updated
permission form arrives at school. New forms are available in the central office.
Parent’s signature______________________________________________
Date______________________
Please return this form to the central office where the original will be filed and a copy made for the student’s teacher.
DRAFT 05/04/11