Permission For Prescription Medication
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1South Bend Community School Corporation
Special Education Services
215 S. St. Joseph St, South Bend, IN 46601
Ph: 574.283.8130 Fax: 574.283.810
Permission For Prescription Medication
Student: ___________________________ SBCSC ID#: _____________ STN#: ________________________
DOB: ________________School: _________________ Physician: ____________________________________
(please print)
Physician’s Authorization For Medication
The above named student requires the administration of a prescription medication during
school hours. This medication should be administered as follows:
Medication
Dosage
Time
Dates To Be Administered
__________________
________
_______
__________________________________________
__________________
________
_______
__________________________________________
__________________
________
_______
__________________________________________
__________________
________
_______
__________________________________________
__________________
________
_______
__________________________________________
__________________
________
_______
__________________________________________
________________________________
_________________________________________
Date
Physician Signature
Parent Authorization For Medication
I _______________________________, parent/guardian of _________________________________________
(Please print parent/guardian name)
(Please print student name)
do hereby authorize school personnel to administer medication to the above mentioned student during school
hours in accordance with the physician’s written instructions.
I understand that medication can only be administered as defined in the Student Medication Procedure of the
South Bend Community School Corporation. Medication must be in the original prescription bottle.
_________________________________
______________________________________
Date
Signature of Parent/Guardian
8/18/12
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