DCS Retreat Medication Form | Dominion Christian School

Parent Name*

First

Last

Email*

Student Name*

First

Last

Grade

Medication 1*

Dosage (ex: 50mg) 1*

Method 1*

Time of day 1 (choose all that apply)*

AM

Lunch

PM

Medication 2

Dosage (ex: 50mg) 2

Method 2

Time of day 2 (choose all that apply)

AM

Lunch

PM

Medication 3

Dosage (ex: 50mg) 3

Method 3

Time of day 3 (choose all that apply)

AM

Lunch

PM

Comments/Notes

I hereby authorize the personnel, employees and officials of the Dominion Christian School to assist my child in taking prescribed medication according to instructions and I release them from any liability for administering this medication.

Authorization to dispense medication.*

Yes

Medication Form Submission

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