Parent Request for Prescribed Medication
Students requiring prescription medication may have this medication administered by
employees of the Horizon School Division provided that the following information is supplied:
School Name:
____________________________________________________
Name of Student:
____________________________________________________
Name of Doctor:
____________________________________________________
Doctor’s Address:
____________________________________________________
Doctor’s Telephone: ____________________________________________________
Name of Medication: _____________________________________________________
Doctor’s detailed instructions for administering the medication and information regarding
repercussions or side effects of the medication:
______________________________ ____________________________________
Parent/Caregiver
Parent/Caregiver
The decision on whether or not to administer the medication is to be made by the Principal
and/or Superintendent of Learning.
___________________________________
Principal/Superintendent of Learning (Student Services)
Superintendent of Learning (Safe and Caring Schools)