Child’s Name:
CR#:

Medication:
Dose:
RX#:

Reason:
Administration Time:

Possible side effects:

Administration Dates: from to

Please specify where medication will reside:

Prescription medication must be in the original container as dispensed by the pharmacist. The label must include the student’s name, name of medication, dosage and have current date.

Over-the-counter or non-prescription medications must be in the original packaging with all directions, dosages, contents, and proportions clearly indicated. Please provide a doctor’s note with instructions and dosage.

All medications, including refills, must be brought to school by the parents and left with authorized school personnel. Students are not to have medications in pockets, lunch boxes or backpacks at school.

I have read and understand that these procedures are intended to help assure the safety of my child as well as other students attending Desert Garden Montessori.


By typing my name below I agree to conduct business with Desert Garden Montessori by electronic means. I intend by typing my name below to “sign” the preceding document and to be bound by its terms and conditions.

Parent Signature:

Email:

Date: