Prescription Permission Form

School Administration of Prescription Medication
Childs Name
Date of Birth

MonthDayYear
Date
Medication
Dosage
Purpose of Medication
Route
Frequency (e.g.,Note special storage requirements: daily)
Time medication to be given at school Lunch times vary 1030a 1p
Frequency eg daily
please specify
Anticipated number of days medicationIs child allergic to any food, medicines, or will be given at school: other items?NoYes (List allergies

until end of current school year

Is this medication a controlled substance?
end date

MonthDayYear
Date
end date

MonthDayYear
Date
Possible Side Effects
I give permission for my child,, to be given the above medication as prescribed by an employed member of The Provision School. I give permission for the school counselor or teacher to contact the health care provider named above or the pharmacist who filled the prescription to discuss this medication and my child's health. I give permission for the health care provider named above, the pharmacist, and/or their designated employees to provide information about this medication and my child's health to the school counselor or teacher. I understand that the school may require that I agree to the school's rules about medications before this medicine will be given at school. I understand that I am responsible for notifying the school if my child's medications change in any way.
Signature of Parent Guardian

Clear
Date

MonthDayYear
Date
Is child allergic to any food, medicine, or other items?

Type option 1Type option 2
Type a question
Note special storage requirements:

Type option 1Type option 2Type option 3
Anticipated number of days medication will be given in school:

Type option 1Type option 2Type option 3
Is this medication a controlled substance?

Type option 1Type option 2
Student Name:
Should be Empty: