Medication Administration Release

* Please only use for Over-The -Counter medications.

Prescription medications require signature by medical provider. *

Student's Name

First Name

Last Name

Medication Name

Dosage Amount

Frequency or Times To Administer

Further Instructions

Email

Phone

(###)

###

####

I Give Permission to Trinity School

Yes

Please Call Me

PIN Number

Note: By providing your assigned PIN number, you are giving the same consent as your signature.

Person Giving Consent & Relationship