Nurse Home | Med. Consent (Eng.) (Sp.) | Physical Exam (Eng.) (Sp.)

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NOTICE OF CONSENT TO ADMINISTER MEDICATION

We/I the parent(s) of ____________________________________________

D.O.B	________/	________/	________/	Grade:_______________
	Mo.	Day	Year

Give consent to The American School of Asunción personnel the Nurse, Principal or Counselor to administer prescribed medication to my son/daughter while on school premises.

Name of prescribing Physician:_____________________________________________________________

Medication	Dosage	Administration Schedule
1.	1.	1.
2.	2	2.
3.	3.	3.
4.	4.	4.
5.	5.	5.
6.	6.	6.
7.	7.	7.
8.	8.	8.

Parent:_____________________________________	Date:__________________________
Nurse:_____________________________________	Date:__________________________
Administration:_______________________________	Date:__________________________
Counselor:__________________________________	Date:__________________________