Medication Permission Form

In accordance with the policy on the administration of prescription and non-prescription drugs, herbs, supplements, and any medication to a student by school personnel, we require that such students should be required to complete this form in order to establish parental authorization and consent. There should be a new, separate form for each medication. Moreover, a written statement from the doctor/dentist accompanied by written permission from a parent before medication can be given to a student by school personnel. This includes over-the-counter medication. 

Finally, the medication must be in its original container with the affixed label from the pharmacist. With regard to prescription medication, one must show the date, student’s name, name of the medication, dosage directions, licensed prescriber’s name, and Rx number (if there is one). A written order from the physician is required for a student to carry an inhaler or Epi-Pen. The following information is necessary to comply with this policy.   

  • That, we must complete this form and have it on file by the school in order to give consent and allow the administration of the medication to my child.
  • That. we must bring the original container of the medication as well as all available information related to such medication as herein required from us.
  • That, I will notify the school if the medication or dosage is changed or discontinued by the prescribing physician/dentist.
  • That, I authorize and request the school and any of its designated employees to administer the above drug or medication to my/our son/daughter.
  • And agree to discharge the school and its District Board of Education, Board members individually and employee(s) of the district who administer prescribed medication from any liability, actions, claims, and demands of any kind that we may have or for our child’s behalf for any injuries, losses, and damages that our child may sustain from the administration of the prescribed medication or any injury or damages that may result from our child’s failure to take the prescribed medication because of a fault or negligence directly attributable to my child.
  • If an authorization to carry Epi-Pen is indicated by a physician, I will provide a backup dose of Epi-Pen. Emergency medical services will be called if Epi-Pen is administered.
  • If a student carries an inhaler, an authorization to carry must be noted in the above instructions.

 I understand and give my permission for the school’s designated employee to administer the medication as prescribed to my child %child_first_name% %child_last_name%.