HILLCREST MIDDLE SCHOOL
PHYSICIAN'S PERMISSION TO ADMINISTER MEDICATION

STUDENT'S NAME: ________________________  BIRTHDATE: ________________

NAME OF MEDICATION: ________________________________________________

DOSAGE OF MEDICATION: _____________________________________________

TIME OF DAY MEDICATION SHOULD BE GIVEN: ____________________________

DIAGNOSIS: _________________________________________________________

SIDE EFFECTS: ______________________________________________________

CONCERNS ABOUT THIS STUDENT: _____________________________________

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PHYSICIAN'S SIGNATURE: __________________________  DATE: _____________

ADDRESS: ____________________________________  PHONE: ______________

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I hereby give my permission for exchange of confidential information in the record of my
child between the School District of Greenville County and the above named Physician's
office.

_____________________________________________    ____________________
                             Signature of Parent/Guardian                                                                  Date