School Medication Permission Form

SCHOOL MEDICATION PERMISSION FORM

Student Name:______________________________________ Date of Birth _______ Grade/Class ____ Teacher:__________ School ____________________

TO BE COMPLETED BY HEALTH CARE PROVIDER Please print clearly and complete ALL sections.

STRENGTH

NAME OF MEDICATION

DOSE

ROUTE (circle)

FREQUENCY

DIAGNOSIS

START

STOP DATE

(If medication is for asthma reverse side of

(include minimum time

DATE

form MUST be completed by health care

interval for prn dosing)

provider and parent.)

Tablet/Capsule (oral)

__/__

Liquid (oral)

______________________

__/__

OR

Inhaler/Nebulizer

OR

END OF SCHOOL

Other_________

as needed every ______ hours

YEAR (circle)

Tablet/Capsule (oral)

__/__

Liquid (oral)

_____________________

__/__

OR

Inhaler/Nebulizer

OR

END OF SCHOOL

Other_________

as needed every ______ hours

YEAR (circle)

Tablet/Capsule (oral)

__/__

Liquid (oral)

______________________

__/__

OR

Inhaler/Nebulizer

OR

END OF SCHOOL

Other_________

as needed every _____ hours

YEAR (circle)

Precautions and/or adverse reactions to report____________________________________________________________________________________________

Date: _____ Health Care Provider Signature: ____________________________________

Health Care Provider Name _____________________________

Address___________________________________________ Phone Number: _____________________ Fax Number: _____________________

TO BE COMPLETED BY PARENT OR GUARDIAN

: I give my permission for (Name of child)_____________________________) to receive the medications listed above at

school according to standard school policy. The school nurse (or other school personnel) involved with the supervision of my child’s health) has my permission to exchange

health information with the health care provider.

Parent/Guardian Signature: ______________________________ Parent/Guardian Name: ______________________ Date: ____________

Parent/Guardian Phone Numbers: Cell __________________ Home________________Work_______________ Other ____________

Please note: Medication must be delivered to school by a responsible adult in the container in which it was dispensed by the prescribing health care provider, licensed pharmacist

or pharmacy. If the medication or dosage is changed, a new form must be completed.

THIS FORM MUST BE COMPLETED EVERY SCHOOL YEAR.

_______________________________________________________________________________________________________________________________________________

TO BE COMPLETED BY SCHOOL: Date received at school: _________ School Nurse Signature:________________________

Principal Signature:________________________

Rev. Shaker Schools March 8, 2012