Medication Consent Form

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Please complete this form if your child has any prescribed medication(s) that must be administered during school hours.

A separate form must be filled out for each child that requires medication(s).

Email *

Student Name *

Student Date of Birth (DOB) *

MEDICATION #1

Name of Medication *

Diagnosis (Reason for Medication) *

Dosage (Amount to be Given) *

Administration (Time to be Given) *

OPTIONAL ADDITIONAL COMMENTS:

Medication #2 (if applicable)

Name of Medication

Diagnosis (Reason for Medication)

Dosage (Amount to be Given)

Administration (Time to be Given)

OPTIONAL ADDITIONAL COMMENTS:

I, the undersigned parent or legal guardian, hereby grant Plato Academy of 915 Lee Street in Des Plaines, Illinois, the authority to administer the medication(s) listed in this form for the above named child.

I will submit to the school office any Emergency Action Plans and/or Treatment Authorization Forms provided by our doctor.

I will provide the school with the above listed medication(s).

Please list YOUR full name which will serve as an electronic signature and agreement.
*

A copy of your responses will be emailed to the address you provided.

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