• Section 10.52.F.3 - Physician's Statement

Student Information

Physician Information

  • I ____________________________ have instructed the above named student/patient in the proper use of (medication)____________________. It is my professional opinion that the student/patient be allowed to carry and use noted medication by him/herself.

    Physician Signature: __________________________ Date: ____________

Parent/Legal Guardian Information

  • I (parent/legal guardian) __________________________ accept full responsibility and liability for my child's actions in regard to use of medication at school and school functions.

    Parent/Legal Guardian Signature: ___________________Date:____________
  • Note- Upon submit you will be able to download/email a copy of this form to yourself in order to have the remainder of the form completed by the Physician.

  • Reference: Section 10.52 Form 10.52.F.3