Medication Permission Form

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Medication Permission Form - High School

Please complete and submit this form if you child will need to take medication while at school. This form applies to scheduled and/or medication taken as needed (pain relievers, etc)

**If your student has more than one medication, please submit a separate form for each one.

All prescription medication must be brought to school in it's original container including the pharmacy label.

All over the counter medication must be brought to school in it's original, unopened container.

Student First Name *

Student Last Name *

Student Grade *

Medication Name & Dosage *

Recommended Time of Administration (if not a regularly scheduled medication, please state "as needed" *

Reason for Medication *

Additional Instructions

I request that the medication described above be administered to my child at the time(s) specified during the school day. I will give the nurse the medication in its original container or current prescription bottle. *

Yes, I (Parent/Guardian) understand and agree to the above.

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