Name of Student:

School:

Grade:

Teacher:

Medication:
Dosage:
 

Diagnosis:

Time of day medication is to be given:
 

Date:
Signature of Physician
 

I hereby give my permission for
____________________________to take the above medication at school as ordered.  I understand that it is my responsibility to furnish this medication.  I further understand that any school employee who administers any drug or nonprescription drug, to my child, pursuant to parental written request, in accordance with written instructions from the physician or dentist, shall not be liable for damages as a result of an adverse medication reaction suffered by the student because of administering such medication.
 
 
 

_____________________________________________________________________
Date:  Signature of Parent or Guardian
 
 
 

NOTE:   The medication is to be brought to school in the original container appropriately labeled by the pharmacy, or physician, stating the name of the medication, the dosage and times to be administered.
 
 
 
 
 
 
 

5/2001