Medication Administration

Please fill out the form below to empower The Forest School staff to administer medicine to your learner at school.

Please Note: Prescription Medication must come in a container labeled with: child’s name, name of medicine, time medicine is to be given, dosage, date medicine is to be stopped, and licensed health care provider’s name. Pharmacy name and phone # must also be included on the label. Over the counter medication must be labeled with child’s name and dosage amount clearly marked. Medicine must be packaged in original container.

Name of parent or caregiver

Primary email address

Name of learner who will receive medication

First Name

Last Name

Please describe the medication, dosage, and timing requested

I affirm the following...

Affirm your willingness for your The Forest School staff to administer medicine to your learner by checking all three boxes below:

The parent/caregiver agrees that the provided medication was prescribed by a licensed health care provider.

It is the parent/caregiver's responsibility to furnish the medication.

The parent/caregiver agrees to pick up expired or unused medication within 1 week of notification.

Today's date

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