Medical Information forms

  • HENDRICK HUDSON SCHOOL DISTRICT SELF-MEDICATION RELEASE FORM Date: __________________________ Student’s Name: _______________________________________________________ has been instructed in the proper use of the following medication: _____________________________________________________________________. We _____________________________________________________________ (and) (Physician’s signature) ___________________________________________________________ request that (Parent or guardian’s signature) (student’s name) ______________________________________ be permitted to carry the medication on his/her person or to keep same in his/her locker or P.E. locker, as we consider him/her responsible. He/she has been instructed in and understands the purpose, appropriate method and frequency of use. Note: This form must be completed in addition to the routine district medication form for those students who request permission to carry their own medication on campus or keep this medication in a P.E. locker.