Tusculum College-Cocke-Hawkins-UB-Medication Form

Tusculum University Upward Bound/Upward Bound Math & Science

Permission for Over the Counter Medications
For the convenience and comfort of our students, Upward Bound/ Upward Bound Math and Science staff have available certain nonprescription medications. Parental consent is required for students to receive these medications.
1. Student Name

First NameLast Name
Email
example@example.com
2. Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearmm-dd-yyyy
3. School
4. Grade
6. Does your child have permission to receive over the counter medications as needed?

Please select which medications we may administer to your child.

18. Your child should not bring these medications with them as they will be available. Should your child need to bring any over the counter medications not on this list, that medication must be documented on the student medication form.
Please initial to indicate that you understand:
19. Any student who shares their personal medication or takes medication belonging to any other student will be immediately dismissed from the Upward Bound/Upward Bound Math and Science Program to which he or she belongs.
Parent Initial
20. Please have the Student initial to indicate that you understand.
21. Custodial Parent/Guardian Signature
22. Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearmm-dd-yyyy
23. Cell Phone
(999)999-9999
24. Home Phone
(999)999-9999
25. Work Phone
(999)999-9999
26. Emergency Contact Name

First NameLast Name
27. Phone
(999)999-9999
28. Student Signature
29. Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearmm-dd-yyyy

Tusculum University Upward Bound/Upward Bound Math & Science