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Medicine Dispensation Form 2007-2008

Victory Life Academy • 901 CC Woodson Rd., Brownwood, TX

I give permission for my child, ____________________, to have the medications which I have checked below administered by his/her teacher, principal or authorized staff person.

Does your child hace any illness or physical problems that the schoos should be aware of?

 No    Yes

If so, please explain.

Does this require medicine?

 No    Yes

If so, what and how is it administered?

In authorizing the faculty and staff of Victory Life Academy to administer the indicated medicine(s), I agree to assume all responsibility in the event of any ill effects sustained by my child. I understand that my child will not be given medicine unless the form is checked, signed, and returned to the office.

Parent/Guardian                                                   Date                                                        

Prior to giving medication, the administration will try to contact the parent. If this is not possible, this form will serve as parental authority for the child to be given the medication(s) indicated above.

Administration Record: Initial each time medicine is given.