Medication Form

Medication Form
Student Info
Child's Name*

First NameMiddle NameLast Name
Child's Grade*
Parent's Name*

PrefixFirst NameLast Name
Phone Number*
Please enter a valid phone number.

Medication Policy

Breath of Life Preparatory Academy will administer medication to children for whom a plan has been made and approved by the Headmistress. Because medication poses an extra strain on staff and having medication in the facility is a safety hazard, parents/guardians should check with the child’s health care provider to see if a dose schedule can be arranged that does not involve the hours the child is in the care of this academy. Parents/Guardians may come to administer medication to their own child during the day. If a liquid oral medication is to be administered at the facility/center, the parent/guardian must provide the administration device with clearly marked measurements (medicine sip-vial, medicine cup, dropper, or syringe.)
Medication at School:
- Requires parent/guardian to complete and sign this Medication Administration Form; form shall be kept in the child’s record with all supportive documentation.
- Medication must be in original, child-proof container and labeled with child’s name.
- All medication containers and dispensers will be stored out of the reach of children and in a locked cabinet, or refrigerator if necessary, and will be returned to the parent/guardian when completed.
  Requires a written plan to record the administration of all medications and to inform the child’s parent/guardian daily when such medications have been given.
  When no longer needed by the child, or when the child withdraws from the program, all medications should be returned to the child’s parent/guardian or disposed of after an attempt to reach parent/guardian.
Prescription Medications:
- Medication is administered in accordance with the pharmacy label directions as prescribed by the child’s health care provider.
- The instructions from the child’s parent/guardian shall not conflict with the label directions as prescribed by the child’s health care provider.
Non-Prescription (Over-the-Counter) Medications:
- Will not be administered.
I, Parent's Name* Last Name* hereby authorize Breath of Life Preparatory Academy to administer the following medication to my child, Child's Name* Last Name* . I further agree to indemnify and hold harmless Breath of Life Preparatory Academy, their agents, and staff against all claims as a result of any and all acts performed under this authority.

Child's Condition*
Name of Medication*
Method of Administration*
Duration of Administration*
Time of Administration*
Purpose of Medication*
Possible Side Effects*

Emergency Information
I, First Name Last Name , do hereby state that I am the parent/legal guardian of First Name Last Name, a minor child age Age , born on Birthdate , who resides with me at Street Address City State. I authorize, for emergency purposes only, a BOLPA designated employee to transport the above minor by ambulance and consent to any necessary examination, anesthetic, medical diagnosis, surgery or treatment, and/or hospital care to be rendered to the minor under the general supervision of any physician or surgeon licensed to practice medicine in the State of Tennessee.
I hereby give consent for BOLPA to secure any and all necessary emergency medical care for my child. In the event I cannot be reached to make arrangements for emergency medical care, I authorize the person in charge to take my child and seek medical attention.*
Preferred Hospital/Clinic for Acute and Emergency Care
Emergency Care Facility Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Provider
Policy Number
Emergency Contact*

PrefixFirst NameLast Name
Cell Number*
E-mail*
example@example.com
Should be Empty:

Medication Form

Student Info

Medication Policy

Emergency Information