Date:_______________________
Student’s Name:________________________________Birthdate:__________________
Parents’/Guardian’s Name:__________________________________________________
Address:______________________________________Home Phone #_______________
City:__________________________________ Parent Work Phone #_______________
Doctor’s Name:________________________________ Office Phone #_______________
Doctor’s Address:_____________________________________Fax # _______________
Type of Illness:___________________________________________________________
Name of Medication:__________________________________
Type:________________ (Tablet, liquid, MDI, etc.)
Possible Side Effects:______________________________________________________
Dosage:_________________________ (mg., puffs, etc.)
Time(s) to be administered:_________________ (mg., puffs, etc.)
______________________________________________________Date:_____________
Physician’s Signature
I hereby permit the Janice Mitchell Isbell Academy, or representatives thereof, to administer my child the above named medication, in the dosage, and at the time(s) indicated.
______________________________________________________
Parent’s Signature
Date:_____________
JMIA FORM 3, 7 August 2001