MEDICATION PERMISSION FORM
STUDENT NAME: _____________________________________________
MEDICATION: _______________________________________________
DOSAGE (amount to be given):___________________________________
TIME(S) TO BE GIVEN: ________________________________________
BEGINNING DATE: ___________________________________________
ENDING DATE: _______________________________________________
I give consent for my child to be given the above named medication while at school. If prescribed by a physician I understand that the doctor’s prescription must be attached to the original bottle which is to be kept at school.
PARENT SIGNATURE: _________________________________________
TODAY’S DATE: ______________________________________________
MEDICATION PERMISSION FORM
STUDENT NAME: _____________________________________________
MEDICATION: _______________________________________________
DOSAGE (amount to be given):___________________________________
TIME(S) TO BE GIVEN: ________________________________________
BEGINNING DATE: ___________________________________________
ENDING DATE: _______________________________________________
I give consent for my child to be given the above named medication while at school. If prescribed by a physician I understand that the doctor’s prescription must be attached to the original bottle which is to be kept at school.
PARENT SIGNATURE: _________________________________________
TODAY’S DATE: ______________________________________________