BETHEL PARK SCHOOL DISTRICT Bethel Park, Penasylvania R-EQT.IEST FoR. AD TI"USTRATION oF MEDICATION D{jRING SCHOOL HOTiRS The Bethel Park school District requests that medication bc givca at home dunog sog-school bours- 6owcvcr, it r€cogE:es that ssmefi"ncs it i* esscatial formedircatioa to !6 adrninislcrcd af schoo!- No "over-the-cormter" medicatioa ?7ii1 bc gvaa io ally studeni witLout an ord'er froa a physiciaa, alongvith sigaatures from the physiciaa z.ad parent(s). 'aji raqiication MUST be is a Pbafiaacr lab€lcd cou.taiacr- The labei nust iaclude the aaac a:ed phoae -'.n!61of thc -cira:=racy, thcpupil's rta.EBe, thc physician's Ea.Ee, thcmcdicatio4 theorrentl-v prcscribed dosc, rimg sfartministratio- aeg ftc P; nrm.ircns Mc<iicatioa datc<i reithiE thc iast two wecks asd to sg zH'niEislsrcd. No MoRE TIIAN 10 scHool Da-l's rcgaires a paieat's/guardiaa's sis.aturc aad the complction of the inforsatioa bclow- fr{criisatioa prcscribcd for loagcr ti"?n a two-r*k pcriod also rcqu:res tle prescriblag pbysician,s sigsaturs- STIjDE}.IT'S NAME LtsST FIRST GR.A-DE AGE PIIYSICIAN"S NAME (print) PHONE r::-ders!e'ad fully tlre directioa-s ti'at have becu given to the school by the ph5rsrciaa aad agre to prait ile sbool ;s 2'{-ni:li5tr tlis medicatioa to my child- rr coasidcration of tie school district's agrecr,rear ro us good faiti efforts "o pio=cil;- ad:eiaister rhis mecica'cca, thedis*ct ishereby reiievcd from liabiiityfora-ayfailurc io propcriy pr{-.:hi5i3; L2 i'ai sa'rcc- I aiso authonze the school to'co!.tact said phisician rega-rding this mcdicatioa- DATE PARENT/GUARDIAN SIGNATURE ITOME PHONE WORK PTIONE c.i tiedici-D.e: ;i Diagsosis{Reasoa medica.ticn is prescribed): Route: if -.eCicire is to bc gi"ea 'TV-IIEN NEEDED-" desc-* iadi=tiors: ti irow soo-rr-c:., it bc repatcti? Lisi signiiica-lt sids effects: ixagtb of tit g this treatsest is rscor.i".eaCcd: Lia--ijciec io be givca DAILY, "1o62i tirne? Ciier i:fo;a.atios: Da!.c Physicia.'s si grat.ui-e