Permission Form For Prescribed Or Over-The-Counter Medication

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STUDENTS
09.2241 AP.21
Permission Form for Prescribed or Over-the-Counter Medication
School _____________________
Date form received by
the
School: _________________________________
Student's Name:
Grade: ______
Homeroom/Classroom:
Student's Age: _____
Date of Birth:
TO
BE COMPLETED BY THE PHYSICIAN OR AUTHORIZED PRESCRIBER
Name of
medication: __________________
Reason
for
medication:
Prescription medication
Over-the-counter
medication provided
by
parent/guardian
Form
of
medication/treatment:
Tablet/capsule
Liquid
Inhaler
Injection
Nebulizer
Other
Describe schedule
and
dose
to
be
given at school:
Starting Date:
date
form received
Other, as specified: _______________________
Stopping Date:
for episodic/emergency
events only
end
of
school year
Other date/duration:
Restrictions
and/or
important effects:
Yes Please describe:_______________________________________
NOTE: In the event the Principal/designee is notified of the possibility of an adverse or extreme reaction to a
medication, she/he shall inform the student's teacher(s) of such a possibility before the student begins the
medication schedule.
Special
storage
requirements:
None
Refrigerate
Other ______________________
Student
is capable of/responsible
for self-administering this medication:
No
Yes
Supervised
Unsupervised
Student
must carry
this medication on his/her person:
No
Yes
Please
indicate
additional
information:
On
the back side of this form
As an attachment
Physician/Authorized Prescriber's Signature
Date
Signature of Parent/Guardian for Over-the Counter Medication
Date
Physician's Name:
Address:
Phone #:
Fax #:
To the school: Please report concerns about medications or the student's condition to the
above
physician.
TO BE COMPLETED BY PARENT/GUARDIAN
I
give permission
for __________________________ to receive the above medication
at
school according to
Student's
Name
standard
school policy
and
expressly waive any liability on behalf
of
the school
as
a result of administration of the above
medication I
understand
that I have the ultimate responsibility for providing the school with an adequate supply of
medication to enable the physician's orders to be followed.
Date: ________________ Signature: __________________________________________ Relationship:
Home Phone: __________________
Work Phone: _____________________
Emergency
Phone:
TO BE COMPLETED BY SCHOOL PERSONNEL
I/we
acknowledge receipt
of
the foregoing
Physician's Statement and
Parent's
Authorization.
Administrator/designee _____________________________________ Date _______________________________
Review/Revised-
6/28/99

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