Murdale Baptist - SWOC Medication Form

SUMMER WEEK OF CHOIR
MEDICATION FORM

Medications your child(ren) take during the day must be left with our SWOC Secretary, Amber Reed, RN, to be administered by her at times specified by the parent(s) or guardian(s). Students may not keep medication with them during the day.

Student's First Name

Student's Last Name

Gender (choose one)

Birthdate

Grade Just Completing (choose one)

Parent's or Guardian's First Name

Parent's or Guardian's Last Name

Preferred Phone Number

Alternate Phone Number

Medication Name

Dosage & TImes to Administer

Purpose of this Medication

Possible Side Effects

Prescribing Physician

Prescribing Physican's Phone Number

Dispensing Pharmacy

Dispensing Pharmacy's Phone Number

Please ask the pharmacist for a separate, labled medicine bottle to be kept in the SWOC Office during the week. It is best if you supply only the amount needed for the week so that you do not have to find the SWOC Secretary/Nurse to retrieve the left-over medication.

Medication Information for Second Item (if needed)

Medication Name

Dosage & Time(s) to Administer

Purpose of this Medication

Possible Side Effects

Prescribing Physician

Prescribing Physician's Phone Number

Dispensing Pharmacy

Dispensing Pharmacy's Phone Number

Please ask the pharmacist for a separate, labled medicine bottle to be kept in the SWOC Office during the week. It is best if you supply only the amount needed for the week so that you do not have to find the SWOC Secretary/Nurse to retrieve the left-over medication.

Parent/Guardian Signature

Date Form Signed and Submitted

SUMMER WEEK OF CHOIRMEDICATION FORM

SUMMER WEEK OF CHOIR
MEDICATION FORM