Medication - Parental Permission to Administer Medicatation in School

Parental Request/Permission to Have Medication Administered in School

If it is necessary for your child to receive medication during the school day, please do the following:

Send the medication to school with a responsible individual if you are unable to take it to school.

Send the medication in the original container. If a prescription, the container must be properly labeled with correct name, time, dose, date, and prescribing licensed healthcare provider.

Count the tablets (unless the number of tablets is the exact number on the label) or approximate amount of liquid in the bottle.

Pick up the medication from school at the end of the school year.

Today's Date

Date

Student's Name

Student Date of Birth

MM/DD/YEAR

Medication Name

Dose

Number of tablets sent

Amount of liquid

Medication Rx Expiration Date

Time

Reason for Medication

Allergies to any medications

I am aware that the school nurse may need to contact the prescribing healthcare provider or pharmacist relative to the medication/treatment and that he/she is required to use nursing judgment regarding all medication administration. I give my permission for medication administration by the school nurse I also give permission for my student's teacher to assist him/her with the above medication on all field trips for the current school year.

Parent/Guardian Signature

Nurse's Signature