2014-2015 SMS Medication Administration Permission and Record Sheet
(one form per child per medication)
Student’s Name____________________________Age/Grade_______Today’s Date___________
Starting Date_____________________________Stopping Date___________________________
Name of Medication______________________________________________________________
Reason for Administration__________________________________________________________
Is this Medication: (circle one)
Over the Counter
**prescription medicine needs to be in the original bottle dispensed by the pharmacy with the instructions for
administration on the bottle.
**over the counter medicines must be in the original containers & dose appropriate.
Dosage_____________________________Time Medication to be Given________________
Route: Oral_____________Nasal___left, right,both __________ Eye Drops____left, right, both
Topical___________location to be applied______________Inhaled_________________
Injection_________location to be administered_________________________________
Should Medication be Taken with Food: (circle one)
Any Previously Known side-Effects___________________________________________________
As the parent/guardian of this child I give my permission for the school staff of St. Monica School to administer the
above medication per the above instructions. I also acknowledge that I have provided the school with the above
medications in accordance with the Archdiocese policy. This can be updated every year via parent initials.