EDUCARE: AUTHORIZATION TO ADMINISTER INTERNAL MEDICINE St. Helen's School 1801 Union Street - Niskayuna, NY 12309 (518) 382-8225
A. For Parent
I, ________________________________________________________ request that the Teacher (or other authorized personnel) (Name of Parent / Guardian) administer medication to my child ______________________________________________ (Child's Name) ______________________________________________ (Parent's Signature and Date)
B. For Family Physician
This is to certify that _________________________________________________ is being attended and treated by me. It is essential that he/she be given the following medication in the dose indicated below during school hours for treatment:
What treatment is for:		__________________________________________________________________
Name of Medication:		__________________________________________________________________
Dosage Schedule:		__________________________________________________________________
Possible Side Effects:		__________________________________________________________________
Length of time to be given:
		Indefinitely
		OR
		from (date) _____________________________to be discontinued on (date) _____________________________
______________________________________________________ Physician Signature ___________________ Date