ࡱ> ,.+a &jbjb11 [[& 2222222hp p p p | h9  ,RA 2 22  2 2 FZ2222 22 7Kp 09   2hhlhhl PARENTAL REQUEST AND AUTHORIZATION FOR THE ADMINISTRATION OF OVER THE COUNTER MEDICATION I am the parent/guardian/custodian of______________________________________________________ (Students full legal name), date of birth__________________ in the _____________________________ Building in the Ogden Community School District. I request and authorize school personnel to administer the following medication to my child: Name of Medication: ____________________________________________________________________ Commence Administration on: ____________________________________________________________ Last Day of Administration: ______________________________________________________________ Dosage, Time and Method of Administration: ________________________________________________ Special Directions and Sign or Side Effects to Observe: ________________________________________ I understand that medication must be delivered to the school office in the original container. I understand the request and authorization must be renewed each school year. I agree to cooperate with school personnel if questions arise. Final determination as to whether or not any medication will be administered by school personnel rests with the schools administration. PLEASE NOTE: In the event of early dismissal 10:45 to 11:15 or before for weather related conditions, Medications will not be administered even if lunch is served. The nurse will not call to remind you. Please call Tammy Wirtz, District Nurse, if you have a concern. Dated this _______day of_______________, __________. _________________________________________ ___________________________________ Parent/Guardian/Custodian Home Telephone Number _________________________________________ ___________________________________ Business Telephone Number _________________________________________ Address ___________________________________ Email Address BZ #& 5>*CJ5CJ5 DO78J K L    %0&d P ]0^ %0]0^ %^ %& \ ]  & ' 3 4 i j k ? @ /Y_n & %0&d P ]0^ %0]0^/ =!"#$%8@8 NormalCJmH sH tH DA@D Default Paragraph FontZi@Z  Table Normal :V 4 l4a _H(k@(No List &  z& DO78JKL\]&'34ijk?@/Y_ n ( 000000000000000000000000000000000000000000000000DO78JKL\]&'34ijk?@/Y_ n ( 8C88888888888888888888888888888888888888888888888&  & & ( ( @@^O& @ @UnknownGTimes New Roman5Symbol3 Arial hY;FY;F fw^!r4dF _G PARENTAL REQUEST AND AUTHORIZATION ocsdOCS Oh+'0$ ( 4@ ` l x 'H PARENTAL REQUEST AND AUTHORIZATION ocsdNormalOCS2Microsoft Word 11.3.5@F#@NV$@f0)@f0)w^GlPICTdb HHb bHHbb          \o{wo{o{wg9wwo{wkZwwwkZwwg9kZw kZwkZwo{wwo{o{kZe^ZZVVkZZ^w^V^RVJRkZ ZVVR^^ZRRc ZVwkZkZZNskZg9ZRsrkZwo{wkZwkZwo{wwo{kZo{wkZo{kZo{kZwwg9kZo{ wwo{o{wo{wkZwo{ww:kZZRV^o{VZZkZNskZ^sZg9kZZNskZZg9ZR^ZskZZRw^VRRkZ^ZsVg9^^o{kZ^Vg9kZZNskZ     3o{swwwwsGkZZZo{kZ^^ZZkZNskZRcZkZVRckZccg9kZZVF1ZkZC swwswwwwswssWg9RkZcVNskZckZckZR^ZVZZo{^kZRZRZkZV^RZkZ^^;o{w sswswsskZ[&VcJRZ^ZkZ^^ZVV^cZwZZRZc^g9Rc^ZZNsg9kZkZZkZw  Mo{wsswwwsswwsw.kZkZ^^c^ZZcVZckZJRkZV^g9c^ZZR^kZg9Nsc^kZkZZZVZZo{g9kZ^kZkZ^kZZkZZ ^ZVVZZkZRckZZc^JRso{wsw/VZZVZkZVkZ^VZZkZRcs  swww; ZwZZRo{Nsc^ZVZ kZkZZkZRcZcs  o{o{sww7 cZg9kZVVg9ZkZZVZkZkZZkZRcs  /o{kZ wssswswwQVVg9Z^^g9Ro{^ZcVVkZ^RZVZkZZVZkZkZZkZRcs    9skZwsswkZssswa)RZ^cRNsZ^VRcg9ZcVRVcZkZRNs^VkZkZNskZg9RZo{Vg9RkZ^s    ]o{wwswwwww sswssswEkZccV^ZkZZJRRZkZZVVZZkZRcZZg9kZV^V^R^kZ^VkZZkZ^^g9NsZZkZZkZVVo{ckZ^^ZkZVZZVZckZZZ^kZw  Io{wwswswwssw4kZccV^ZkZZJRR^kZ^^c^ZZcVZckZ^ZkZVZkZRcZZg9kZV^kZ^c^Z^V^ZNsg9c^Z^Rw  )o{sswwsi-kZZ^kZ^^kZZcZZJRkZZRZ^^g9c^ZZR^kZg9ZccR^^c^g9kZRcg9ZkZZ^w  SkZwwsswwwwwwswwLg9ZZkZVR^kZZZRRcZg9kZZZ^^R^kZZkZcZkZZcg9Zo{^F1ZkZRcZRV^ZVZo{ZZkZ^RVVg9R^ZZkZZ^kZg9Nsc^kZ^g9Z#sssww=Zo{kZ^kZ^^g9c^ZZg9NsVZkZkZZkZRcw  {o{o{kZwskZo{o{kZkZo{sswwwwwsswssswww^cVZRVVZ^VsVR^^kZ^ckZZkZ^RZVZ,g9ZkZkZVsZZkZZkZkZskZZkZV^kZR^kZZkZZ^ZR^kZkZ^RkZ^VcZcV^Rcg9wYsswwwwwswswkZswww!VkZ^VZZkZRcg9ZF1ZkZV^ZVZo{cZkZR^V^kZ^c^kZc$^o{g9g9^kZRVwkZ^^cckZg9^ZF1ZkZcZkZkZZkZJRZVg9Zcw=o{wwkZkZso{o{wssm/^RZg9^cZkZkZZZRo{g9cg9^RRg9kZkZZkZVckZg9^kZkZg9Zc^ZkZ^ZcZcc^Vw  %o{wsws7VVRVkZ^ZVZNskZww      Qo{wswwswwkZwkZwso{ww_^ZkZ^ckZZ kZVRckZZ^g9RVRcRRZo{^kZ^RZ^Zc^VcZo{VR    +o{kZwso{ww7Vcg9Z^g9g9kZ^RZ^Zc^VcZo{VR  wwwZVVRg9g9kZwww# VZRJRVVkZ^g9                         ՜.+,0L hp  ,' Ogden Community School DistrictF  H PARENTAL REQUEST AND AUTHORIZATION Title  !"$%&'()*-Root Entry F c/1TableWordDocumentSummaryInformation(TDocumentSummaryInformation8#CompObjXObjectPool c c FMicrosoft Word DocumentNB6WWord.Document.8