PERMISSION FORM FOR MEDICATION

Date: ________________

Student Name: ___________________________ Grade: _______ Date of Birth: ___________

Reason for Medication: ___________________________________________________________________________

Name of Medication: _____________________________________________________________________________

Form of medication/treatment:
Tablet/capsule Liquid Inhaler Nebulizer Other _______________

Schedule and dose to be given at school: ______________________________________________________

Start Date:____________________________ End Date: _____________________________

For episodic/emergency events only

Restrictions (if any): _____________________________________________________________________

Special Storage Requirements: No Yes - ____________________________________________

This student is capable of self-administering this medication: Supervised Unsupervised

If there is additional information the school should know please state below:

Physician's Name:________________________________ Date:_______________________

_______________________________________________
Physician's Signature or Doctor's Office Stamp

_______________________________________________ Date:_______________________
Parent/Guardian Signature

All medications must be brought to school in the original container. Inhalers are the only medical items that students can carry.