BRITTAN SCHOOL DISTRICT
2340 Pepper Street
Sutter, CA 95982
822-5155 FAX 822-5143
AUTHORIZATION FOR MEDICATION TO BE GIVEN AT SCHOOL
| Student's Name | Birthdate | ||
| Teacher | School Year |
Dear Parent/Care Provider:
In order for school personnel to dispense any type of medication to your child, the District is required to have an authorization on file from the child's physician and also signed by the parent/guardian of the student. (California Education Code, Section 49423).
| Medication to be administered | |
| Dosage/How often | |
| Time of Day/ Duration | |
| Anticipated reactions to medication |
| Medication to be administered | |
| Dosage/How often | |
| Time of Day /Duration | |
| Anticipated reactions to medication |
| Additional instructions from physician | |
| Physician's Printed Name | |
| Phone | |
| Physician's Signature | |
| Date |
I approve of this authorization for medication to be given to my child by school personnel
| Parent/Care Provider | |
| Home Phone | |
| Work Phone | |
| Date |
PARENT'S AUTHORIZATION FOR EXCHANGE OF INFORMATION
I hereby give my permission for the exchange of information regarding my child's medication between Brittan School and the following:
| Physician | |
| Other |
Signature of Parent/Guardian Date
Please return to: Brittan School, FAX 822-5143
10/02