Non-Prescription Medication Form printable pdf download

Non-Prescription Medication Form

5425 Scio Church Rd.

Ann Arbor, MI 48103

734.665.5662

Fax: 734.665.8126

Non-Prescription Medication Form

AUTHORIZATION FOR ADMINISTRATION OF

OVER-THE-COUNTER MEDICATION DURING SCHOOL HOURS

Student’s name: _______________________________

Birth date (mm/dd/yy): ________________

Name of medication: ________________________________________________________________________

Reason for medication: ______________________________________________________________________

Directions for administration of medication:

____________________________________________________________________________________________

Anticipated duration of medication use:

____________________________________________________________________________________________

I hereby give permission for the above medication to be administered to my child.

________________________________________

_______________________

Parent/guardian signature

Date (mm/dd/yy)

Non-Prescription Medication Form