Permission Form for PrescribedMedication/Treatment
*ALL MEDICATION/TREATMENT MUST BE ADMINISTERED
BY SCHOOL PERSONNEL IN THE MAIN OFFICE.
Date received by school
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
DOB:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Student Name:
(Please Print) Grade:
Reason for medication
Name of medication
Form of medication (CIRCLE):
tablet/capsule
liquid
inhaler
injection
Nebulizer
other
Instructions:
Start:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Stop:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Restrictions/or important side effects: none anticipated
If yes, please describe:
Special storage:
none
refrigerate
Other
Please indicate if you have attached additional paper with this form to provide additional information regarding your child's medication.
Date:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Signature:
Physician's Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Format: (000) 000-0000.
To be completed by parent/guardian:
I give permission for (name of child)
to receive the above medication/treatment at school according to standard school policy.
Date:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Guardian Signature:
Preview PDF
Submit
Should be Empty: