• Shalom School-Based Clinic Medication Consent (Parent/Guardian Section)

    Shalom School-Based Clinic Medication Consent (Parent/Guardian Section)
  • Last Name: * First Name: *
    DOB: Pick a Date* Medication Name and Dosage: *
    Instructions, including TIME to give medication: *
             

  • * For late/delayed arrival, please: 
        *   *
    * For early/alternate dismissal, please:
    *      *
    * I authorize clinic staff to administer the medication as described here. Medication(s) be stored in secure location in clinic.
    * My authorization will be in effect until a termination or change in medication is submitted in writing or at the end of the school year. 
    * I agree to use my child’s patient portal to coordinate medication drop off in advance with the SBC staff. I understand all medications will be counted in with SBC staff and an adult school staff witness. All medications must be labeled. Prescription medications must have a valid pharmacy label. Medication(s) may only be labeled for one student. 
    * Any medication left in the clinic past the last day of school will be wasted/destroyed per Indiana state law.
    * I give permission for my child to transport non-controlled medications to/from school in labeled container.
    * I agree it is my responsibility to notify clinic staff of any changes immediately and in writing. This is to be done electronically through my child’s patient portal
    * Notify me by:      ** doses left of their medication to allow adequate time to get a refill.

  • Signature: *   Date: Pick a Date*   

  • Name: * Daytime#: *
    Relationship to student: * Email: *

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