E3 Legacy Academy

By signing this form, I give my permission for any E3 Legacy Academy staff member to administer the following medications or medical treatments to my child when deemed necessary. The staff member will record the name of the medication, date, time, and the amount given. This form will be kept on file. Medications will be administered according to pre-stated parental directions or according to medication label. We cannot be responsible for medications that the student takes without the knowledge of the teacher or that are self-administered.

I, the parent or guardian of the student listed above, do hereby give my permission to E3 Legacy Academy, its teachers, administrators and staff to request medical treatment for the above-named child in the event of an emergency.