Medication Permission Form

Student: 

D.O.B. 

Allergies: 

Parent / Guardian: 

Phone: 

I, , hereby give the School Nurse, Lea Glaze, and Other Certified Staff, permission to assist my student,   , in taking the following medications:

Over the counter medications (i.e. Tylenol, Motrin, Cough Drops)
Please specify which you will allow your child to take during school and how often (every four to six hours, as needed, etc.)

Prescription Medications:

Name of Medication:

Dosage / Directions:

Time to be Given in School:

Physician:

Reason for taking medication:

Duration of prescription:

I understand that all medications including over the counter medications (even Tylenol, Motrin, cough drops, eye drops, or nasal sprays) must be kept in the school nurse's office.  The only exception to this rule is if a student is an asthmatic and has a doctor's statement that states that it is medically necessary to have my student carry an inhaler.

Parent / Guardian: 

Date:

School Nurse: 

Date: