Medication Permission Form
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1Warren County Schools
School Health Services
Medication Permission Form
Parent
STUDENT
Legal Guardian
Date of Birth
YEAR
Bus
Car
Cell Phone
Work Phone
Teacher
Home Phone
Grade _____
Name of Medication
___ mg per tablet
take _____ tablet(s)
Total______ mg
TIME TO TAKE
___ mg per teaspoon/5ml
take _____ teaspoons
___ after lunch
take _____ puffs
per dose
___ as needed
___ before PE/recess
__ADHD __Headache/Migraine __Fever/Pain __Asthma __Allergy
Reason for Medication
/
Side Effects
Precautions ___________________________________________________________________
START DATE ____/_____/_____
STOP DATE ____ / ____ / ____
Supervised Administration:
School Staff will keep and give this medication for this student.
Self-Administered Emergency Medication:
Student is capable to keep/take this medication on his/her own.
SELF CARRIED MEDICATIONS: INSULIN, GLUCAGON, EPI-PEN AND INHALERS ONLY
Parent Signature for self administration.________________________________ Parent to bring extra for med box.
Healthcare Provider Signature______________________________________________
______________________Date__________Phone__________
Healthcare Provider (PRINT)
TO BE COMPLETED BY PARENT / LEGAL GUARDIAN
I hereby give my permission for my child (named above) to receive medication during school hours. I understand
that the school undertakes no responsibility for the administering of the medication, and this medication must be
prescribed by the licensed physician. I hereby release the school board and its agents and employees from any and
all liability that may result from my child taking the prescribed medication. I also authorize my child's medical care
provider to release information to the school nurse that is deemed necessary for the administration of medication at
school in accordance with the Health Insurance Portability and Accountability Act of 1996
( HIPPA). I agree to provide and maintain an emergency phone contact. This consent is good for the school year,
unless revoked.
Parent/Legal Guardian Signature
___________________________________________Date __________
DAYTIME PHONE NUMBERS
_____________________________________________________________
Teachers Receiving Copies( Include Date)____________________________________________
Student demonstrates adequate knowledge to keep, carry and take this medication.
School Nurse __________________ Date________________
BUS DRIVER NOTIFIED ___________
BUS NUMBER____________
File original in Individual Health Record
Copy to staff administering medication
SS-157
Revised: July 2013
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