Fillable Medication Permission Form printable pdf download

Archdiocese of Galveston-Houston

Catholic Schools Office

Medication Permission Form

Student_____________________________________________________ DOB______________

School ______________________________________________________Grade_____________

Policy for students receiving medication at school whether prescribed medication by a physician or

authorized prescriber or over the counter medication is as follows:

•

Signed orders from the parent/guardian and physician must be on file

•

Over-the-counter medication brought in the original container

•

Prescribed medication with a pharmacy label that matches the written orders

•

All medication must be brought to the school by the parent

•

School personnel may refuse to give the medication

To be completed by the Physician or Authorized Prescriber:

Reason for the medication: ________________________________________________________________

Name and strength Medication: ____________________________________________________________

Form Medication:

Tablet/capsule

Liquid

Inhaler

Injection

Other

Amount and Time/s: ______________________________________________________________________

For PRN state the frequency, the time between dosages of medication, and maximum number of dose in

a school day: _______________________________________________________________________________

____________________________________________________________________________________________

Start date for medication: ____________________

End date for the medication: __________________ (All orders will be valid for the current school year.)

Additional information, instructions, restrictions and/or important side effects: _______________________

______________________________________________________________________________________

_______________________________________________________________________________________

Physician or Authorized Prescriber Signature __________________________________Date____________

Physician’s or Authorized Prescriber name (print):

Name ___________________________________________________________________________

Phone Number __________________________ Fax number _______________________________

To be completed by the Parent/ Guardian:

I instruct the school principal or the principal authorized personnel to give the medication as instructed

above.

Do you want to be called before or after (circle) a PRN medication is given? Yes_____

No_____

Additional information/instructions or restrictions _______________________________________________

________________________________________________________________________________________

Consent

I hereby request that the medication specified above be given to the above named student. I understand that the school

personnel who give the medication may not be a medically trained person.

I realize that the school does not have to agree to allow medication to be given to a student by school personnel. I understand

that the school’s agreeing to allow the medication to be given is for my benefit and the student’s benefit. Such agreement by the

school is adequate consideration of my agreements contained herein. In consideration for the school agreeing to allow the

medication to be given to the student as requested herein, I agree to indemnify and hold harmless the Archdiocese of Galveston

– Houston, its servants, agents, and employees including, but not limited to the parish, the school, the principal, and the

individuals giving the medication of and from any and all claims, demands, or causes of action arising out of or in any way

connected with the giving of the medication or failing to give the medication to the student. Further, for said consideration, I, on

behalf of myself and the other parent of the student, hereby release and waive any and all claims, demands, or causes of action

against the Archdiocese of Galveston – Houston, its agents, servants, or employees, including, but not limited to the parish, the

school, the principal, and the individual giving or failing to give the medication.

Parent/ Guardian Signature ____________________________________ Date_________________________

Printed name________________________________________ Relation to the child ______________________

Special forms are required for severe allergies and administration of Epipens, administration of diabetic

medication, and self-administration and carrying of asthma medication.

Ref: American Academy of Pediatrics

Archdiocese of Galveston-Houston Health Manual

July 2004

Medication Permission Form

Related Articles

Related forms

Related Categories