SCHOOL MEDICATION AUTHORIZATION FORM

School Medication Authorization Form

OTC (Over-The-Counter) MEDICATIONS
ECS requires written permission by a parent/guardian and licensed healthcare provider for administration of any medication at school. Please complete the following information, select your preference of which over-the-counter medication(s) you would like your child to have permission to take, while at school, and provide the appropriate signatures at the bottom of this form. This form will be kept on file in the Health Office/Nurse’s Office and will be valid until graduation.
STUDENT INFORMATION

Name Last Name
Grade
Allergic?

Yes No
The Student is allergic to...
Please select which medications you would like your child to have permission to take during the school day. The Health Office stocks a generic supply of the medications listed below

Stomach Relief (compare Peptobismol) Pain/Fever Relief (compare Acetaminophen) Pain/Fever Relief (compare Childrens Tylenol) Antacid Tablets (compare Toms) Antihistamine Tablets (compare Benadryl)
PARENT/GUARDIAN AUTHORIZATION

I authorize The Episcopal Cathedral School to administer said medications to my child, on an as needed basis.
Name Last Name
Date

Mes Día Año
Sign Here

Clear
Should be Empty:

School Medication Authorization Form