Parent Request for Administration of Medication by School Personnel
Please submit this form to authorize your student to take daily medication or medication as needed.

Note: The school does not provide OTC medications such as Tylenol or Advil. These must be provided by a parent or guardian each school year.
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Student Last Name *
Student First Name *
Grade *
Parent/Guardian Name *
Phone Number *
Medication *
Dosage *
Duration *
Time(s) to be Given *
Condition(s) for which medication in required:
Has your child taken this medication before: *
Required
Medication Allergies: *
Special Instructions:
Medication must be in it's original, properly labeled container and up to date by law. Medications scheduled for three times daily require a physician's written authorization stating that it must be given during school hours. Medications not picked up at the end of the school year will be discarded. By submitting this form I am requesting that HPISD staff administer the medication to my child and grant permission for the School Nurse to contact the prescribing physician, as needed. I release this individual and HPISD from liability due to any allergic or adverse reaction to this drug. *
Required
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