Medication Permission Form
You must sign this document
as evidence of your consent.
Complete the following medication
profile for your child.
A separate authorization form must be filled out for
each
medication administered.
There shall be no liability for civil damages as a result of the administration of such medication when the person administering such medication acts as a reasonable prudent person would act under the same similar circumstances.
Medication must be in the original
pharmacy-labled bottle.
Non-prescription medication
must be in the original packaging with the manufacturer’s label.
(Consent:)
As legal
parent or guardian, I hereby authorize:
(child’s name)_____________________________________ to take the medication that I will provide, and authorize the school to store these medication according to school policies, and assist with administration of the medication as directed. I further agree to inform the school of any changes in medication, including changes in when the medication is taken, change in the dose, new or different medication, a reaction to the medication, or discontinuation of medication. I further understand that this consent applies to all medication, whether prescribed by a physician, or purchased over the counter without a prescription. I understand that this consent applies to this school year only, and next year I am required to sign another consent form
______________________________ ______________________
Parent/Guardian’s
name – Please print Parent/Guardian’s signature
Date_________________
Name
of medication ____________________________________
Medication
dose _________________ Time_____________
Route
of administration____________
Medication
allergies _____________________________________
Indication
for use _______________________________________
______________________________________________________
How
long will your child need to take this medication? _________
______________________________________________________
When medication is discontinued, or a course of medicine is completed, pick up all unused medication within one week.
Unclaimed medications will be destroyed.
*A responsible adult must deliver and pick-up the
medications in the school clinic.