Medical Permission Forms

Request for Medication/Treatment During School Hours

2021-2022
THIS APPLIES TO ANY MEDICAL PRESCRIPTION
Employment Resources Incorporated (ERI) requires that if medication/treatments are to be taken by a student during the school day, the school MUST have the following information completed and on file. In addition, this information MUST be updated as soon as changes occur:

TO BE COMPLETED BY THE PHYSICIAN: (Please print)
Student’s Full name
Medication/Treatment
Dosage and Time Schedule
Diagnosis
Length of Time Medication/Treatment Required
Precautions, Special Instructions, Possible Side Effects, Comments
Name of Prescriber
Signature of Prescriber

Clear
Address
Telephone
Date

Month Day Year
Date
TO BE COMPLETED BY PARENT OR GUARDIAN:
I request that school personnel administer the above medication/treatment ordered by the physician as stated and according to the directions given. I authorize a representative of the school to share information regarding this medication/treatment with a health care provider in an emergency. I understand and agree to comply with the school’s policies and procedures.
Signature of Parent/Guardian

Clear
Date

Month Day Year
Date
REQUEST FOR OVER-THE-COUNTER MEDICATION/TREATMENT Medical Standing Orders

2021-2022
THIS APPLIES TO ANY OVER-THE-COUNTER MEDICATION
Employment Resources Incorporated (ERI) MUST have the following information completed and on file if medication/treatments are to be taken by a student during the school day. In addition, this information MUST be updated as soon as changes occur:
I,
Physician's Name
,authorize
Patient's Name
to receive the following over-the-counter medications administered according to the indications and instructions of that medication’s label.
Check all that apply

Acetaminophen Antacid tablets Antibiotic cream/ointment Calamine (anti-itch topical) Cough syrup Hydrocortisone Cream (1%) Ibuprofen Menthol drops Midol Other: Other:
To my knowledge the patient has the following medication allergies
Prescriber Signature

Clear
Date

Month Day Year
Date
Parent/Guardian Signature

Clear
Date

Month Day Year
Date
ASTHMA AWARENESS INFORMATION

2021-2022
Student’s Name
Date of Birth

Month Day Year
Date
Parent(s)/Guardian(s) Name
Phone
Current Asthma Medication(s)
Known Asthma Triggers: (Click all that apply)

Colds Mold Exercise Tree Pollens Dust Strong Odors Grass Flowers Excitement Weather Changes Animals Smoke Food (Specify): Other (Specify):
Typical Signs and Symptoms of an asthmatic episode: (Click all that apply)

Fatigue Rapid Respirations Dark circles under the eyes Flaring nostrils Persistent coughing Gray or blue lips or fingernails Difficulty playing Difficulty eating Difficulty drinking Difficulty talking Face red, pale or swollen Wheezing Agitation Mouth open (panting) Sucking in chest/neck Grunting Restlessness Complains of chest pain Other(s): Other
Parent/Guardian Signature

Clear
Date

Month Day Year
Date
Should be Empty:

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Request for Medication/Treatment During School Hours

THIS APPLIES TO ANY MEDICAL PRESCRIPTION

TO BE COMPLETED BY PARENT OR GUARDIAN:

REQUEST FOR OVER-THE-COUNTER MEDICATION/TREATMENT Medical Standing Orders

THIS APPLIES TO ANY OVER-THE-COUNTER MEDICATION

ASTHMA AWARENESS INFORMATION