Medication Permission Form

Student Information

First Name

Last Name

Date of Birth

Gender

School Name

Grade

Teacher Name

Health Care Provider Authorization

Medication

Dosage

Time(s) of Administration

Start Date

End Date

Route Administration and Instructions

Reason for Medication

Side Effects/Adverse Reactions

Signature of Health Care Provider

Parent/Guardian Authorization

I give permission to the school nurse to administer the medication as prescribed above to my child. And I also give permission for the school to contact the above health care provider regarding the administration of the medication.

Signature of Parent/Guardian

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