2021/2022 Prescription Medication Permission Form
2021/2022 Prescription Medication Permission FormThis is only for prescription medications taken during the school day. The prescribing physician and parent must complete a NEW form each school year and bring it to the front office along with the medication on the first day of school, or ASAP when new medication is prescribed during the school year.TO BE COMPLETED BY PARENT/GUARDIANStudent First & Last Name:Date of Birth:2021/2022 Teacher:2021/2022 Grade:I am requesting that my child receive prescription medication as designated below. I will be responsible for bringing the medication to school in its accurately labeled container to avoid any interruptions of the medication administration. Failure to do this will result in termination of the medication administration program. I also understand that, if my child refuses to take the medication, force will not be used by school personnel to make my child comply.Parent/Guardian’s Printed NamePermission Effective Through Date*Parent/Guardian’s SignatureToday’s Date*UNLESS discontinued, changed by me, or withdrawn in writing by the child's legal parent/guardian.------------------------------------------------------------------------------------------------------------------------------TO BE COMPLETED BY THE PRESCRIBING HEALTH CARE PROVIDERChild’s First & Last Name:Date of Birth:Medication (Generic & Trade Name)Dosage Time of day / FrequencyPossible/Common Side EffectsI am prescribing the medication(s) as described for the child listed above.Health Care Provider’s Printed NameOrders Effective Through Date*Health Care Provider’s SignatureToday’s DateName of Health Care Provider’s OfficePhone Number*UNLESS discontinued, changed by me, or withdrawn in writing by the child's legal parent/guardian. ................
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