Medical Permission Form For School (Page 2 of 2) in pdf

Insurance Information

Medical Insurance Company Name: _________________________________________ State: _________

Policy Number: ____________________

Name on Card: _____________________________________

Physician’s Name: __________________________________

Phone: __________________________

Authorization for Non-Prescription Drugs

I, the parent/guardian of _________________________________ request, authorize, and give written

permission to Trinity Lutheran School and its representative to administer the medication below in accordance

with the instructions provided.

Medication: ________________________ Dosage: ________________

Frequency: _______________

For symptoms of: _______________________________________________________________________

Parent/Guardian Signature: _____________________________________

Date: ____________________

Authorization for Prescription Drugs

(to be filled out by physician)

Date: ____________________

This is to inform you that _____________________________________, a student enrolled in your school, is

currently under my medical care for: _________________________________________________________.

As a part of that care, this student must receive the following medication and/or treatment:

Medication: ______________________________________________________________________________

Dosage: _________________________________________________________________________________

Frequency: _______________________________________________________________________________

For the symptoms of: _______________________________________________________________________

I request and authorize you to administer this medication and/or treatment in accordance with the above

instructions. These instructions remain in force until ______________________________, or until you are

otherwise notified by me. Problems concerning these prescriptions can be referred to me.

________________________________________________________________________________________

Physician Signature

Physician Phone

________________________________________________________________________________________

Physician Address (Street, City, State, Zip)

Medical Permission Form For School Page 2