Medical Consent Form - All Students printable pdf download

Medical Consent Form – All Students

Physician’s authorization to administer medication at Jackson County School District Schools

Name of School_________________________________________________________________

Name of Student________________________________________________________________

NO STUDENT WILL BE ALLOWED TO BRING ANY MEDICATION TO SCHOOL.

Prescription Medication(s):

Medication

Dosage

Frequency

Physical

Date to Begin

Date to End

Condition

OVER THE COUNTER MEDICATION(S):

Please provide dosage amount and

frequency, along with physical condition for which it is to be given. Include date to begin and

date to end.

Name of medication(s) __________________________________________________________

Directions: (dosage, amount, frequency) ____________________________________________

Include date to begin and date to end (begin) ______________ (end) _________________

All over the counter medications shall require a physician’s order.

________________________________

__________________

________________________

Physician’s signature

Physician’s/Clinic Stamp

Date

I hereby give my permission for exchange of confidential medical information regarding my child between Jackson

County School District and ____________________________________

(Health Care Provider)

This information will be released to effected school staff/personnel with the understanding that it is confidential and

will be used in providing appropriate health care and education for this student.

______________________________________

__________________________

Signature of Parent/Guardian

Date

PARENT/GUARDIAN AND PHYSICIAN’S SIGNATURES REQUIRED FOR ADMINISTRATION OF MEDICINE.

It is requested that this form be returned as soon as possible. This form may be mailed or faxed to your

child’s school. Please contact the school for address or fax number.

Medical Consent Form - All Students