HENDRICK HUDSON SCHOOL DISTRICT
SELF-MEDICATION RELEASE FORM
Student’s Name: _______________________________________________________
has been instructed in the proper use of the following medication:
We _____________________________________________________________ (and)
___________________________________________________________ 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.