Founded 1867
COE-BROWN NORTHWOOD ACADEMY
907 FIRST NEW HAMPSHIRE TURNPIKE
NORTHWOOD, NEW HAMPSHIRE 03261
Telephone: (603) 942-5531
FAX: (603) 942-7537
David
S. Smith, Headmaster
Paul W. Davis, Jr. Asst. Headmaster
Sally
A. Aseltine, Dean Student Services
Stephen H. Smith, Guidance
Anne H. Onion, Guidance
PARENT/LEGAL
GUARDIAN AUTHORIZATION
(Over-The-Counter Medication Release Form)
I hereby request and give my permission
for the school nurse and/or designee to assist my
child, ________________________________in taking the following medication(s)
|
Medication |
Purpose |
Dose |
Route |
Time |
For how long? |
(listed above). I release said person from responsibility for any adverse
effects from the
medication or from the effects when my child refuses to cooperate in taking
said medication(s).
___________________________________ ___________________
(Parent/Legal Guardian Signature)
Date
Other medication(s) child is currently taking:
_______________________________________________________________________
_______________________________________________________________________
Medication must be delivered directly
to the school nurse and/or designee by the parent/legal
guardian or responsible adult in the original container from the pharmacy
or manufacturer’s
container