Medication Consent Form
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2Union County Public Schools Medication Consent Form
School:________________
Telephone: _______________
Fax: ________________
Student Name______________________________________________Birthdate_______________________
Teacher/Grade______________________________________________
In order to help protect your child's health, your consent and written authorization from a health care provider with prescriptive
authority is required when it is necessary for your child to receive prescription and/or non-prescription medicines.
Parent or Guardian's Permission: I give permission for my child to receive this medicine during school hours. I also give
permission for school staff to contact the prescribing healthcare provider with questions/concerns. I understand that it is my
responsibility to purchase and supply this medicine in its original container. On behalf of my child I absolve the Union County School
Board and their agents and employees from any and all liability whatsoever that may result from my child taking this medicine at
school.
_______________________________________________ _____________________________________________________
Signature of parent or guardian
Date
Contact numbers (telephone, cell phone, pager, etc.)
This medication is to be used for emergencies only. Please allow this student to self-administer this medication
*****Both sides of this form are required for emergency self carry medications*****
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Medication____________________________________Strength/Dose____________________________
Medical Diagnosis
: ___________________________________________________________________________________________
Specific Directions
(include amount to give, at what time and/or how often, relationship to meals, specific indications if “as needed”)
How often and/or at what time (hour):_______________________________________________________________________
Purpose of medication
: ___________________________________________________________________________________________
Relationship to meals, if applicable: ________________________________________________________________________
Expected side effects or adverse reactions: __________________________________________________________________
Specific indications: ____________________________________________________________________________________
Other information: ______________________________________________________________________________________
It is necessary for this student to receive this medication during school hours in order to maintain or improve health and to benefit
from school attendance. Please notify the principal and/or school nurse and parents/guardians if there are any problems.
_________________________________________________ _________________________ _________________________
Signature of Healthcare Provider
Date
Telephone
Fax
______________________________________________ ______________________________________________________
Please print practitioner's last name
Practice name /address
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FOR SCHOOL USE ONLY:
Date Received/By: _____________________________________School Health Nurse Review: _________________________
Location of Medicine
on student, emergency medication only
in Health room
in Classroom
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