Permission to Administer Medicine Authorization Form Logo

  • Permission to Administer Medicine Authorization Form

    Parent/Guardian will provide the school with medication in a prescription bottle or original container if medication is over-the-counter. Eastgate Academy will NOT accept any pills in unlabeled bags, etc. No medication will be given without appropriate packaging/dosing instructions.

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    If it is a prescription medication, your child’s physician will need to fill out and sign the bottom of this form. 

    Please select “OTC” whether your child is on a prescription medication or not, and list the over-the-counter medications they are allowed to have (e.g., Tylenol, ibuprofen, Pepto-Bismol, etc.).

     

  • Student Full Name (Please Print) *   *   
    Grade/Teacher   *   
    Name of Medication   *   

  • I request and authorize school personnel to give this medication to this student and to contact the physician directly if there are any concerns about the medication or the student's condition. I understand that I have the ultimate responsibility for providing the school with an adequate supply of medication and to inform the school immediately if any information provided on this from changes OR if the administration of the medicine should stop. I agree to hold harmless Eastgate Academy, 
    Eastgate United Pentecostal Church, and/or any employee, volunteer or representative thereof, for any effects as a result of giving the medication.

     

  • Parent/Guardian Full Name (Please Print)   *   *   
    Parent/Guardian Signature   *      
    Date   Pick a Date*   
    Phone   *   *   
    Email   *   

  • Name of Medication      
    Diagnosis for Medication      
    Route of Administration      
    Dose Prescribed      
    Time Administered      
    How often Repeated?      
    Side Effects      
    Length of Treatment?      

    Physician's Name         
    Phone         
    Physician's Signature      

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