HILLCREST MIDDLE SCHOOL
PARENT PERMISSION TO ADMINISTER MEDICATION

STUDENT'S NAME: _________________________  BIRTHDATE: ______________

PARENT/GUARDIAN: _________________________________________________

HOME PHONE: ____________________ WORK PHONE: _____________________

I request that the following medication be administered to my child by the appropriate
staff member.

                NAME OF MEDICATION: ________________________________________

                AMOUNT OF MEDICATION TO BE GIVEN: __________________________

                TIME OF DAY TO BE GIVEN: ____________________________________

                GIVE MEDICATION UNTIL: ______________________________________

                PRESCRIBED BY: ______________________  PHONE: ______________

                POSSIBLE SIDE EFFECTS: ____________________________________

I understand that this medication will be furnished by me, given to a school staff member
and provided in the original container.  I will notify the school immediately
in writing if the medication has been discontinued or dosage
changed.

_______________________________________________    __________________
                   (Signature of Parent/Guardian)                                                    (Date)

ANY MEDICATION ON HAND AT THE END OF THE SCHOOL YEAR WILL BE
DESTROYED IF NOT PICKED UP BY A PARENT OR OTHER ADULT DESIGNATED BY THE PARENT.