Last Name: * First Name: *
DOB: Date* Medication Name and Dosage: *
Instructions, including TIME to give medication: *
         

* For late/delayed arrival, please: 
give medication when arrives to clinic   hold medication if arrives after *   contact me before giving medication*
* For early/alternate dismissal, please: give medication at
*   hold the medication   contact me before giving medication*
* 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:text   email   call when my child has** doses left of their medication to allow adequate time to get a refill.

Signature: Signature*   Date: Date*   

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