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Non-Prescription Medication Permission Form


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Child’s Name/DOB __________________________________________________ ___________

Grade ______________________

Date __________________

 The school nurse must have this completed form before medication will be given at school.

 An adult must bring the medication to school.

 Medication must be in the original manufacturer’s container. Loose medication in plastic bags will not

be accepted.

 The school nurse must approve and administer the first dose of any medication given at school.

 The school nurse may delegate administration of subsequent doses to another school staff member.

 All medicine must be kept in the nurse’s office.



I give permission for the medication below to be given to my child at school by the school nurse or her designee.

Medication _______________________________________________________

Dosage/Route/Time ________________________________________________

Start Date _________________________ End Date __________________

Reason medication is being given _____________________________________

Signature of Parent or Guardian ____________________________________


Date Received _______ Signature of School Nurse ____________________

*non-prescription medication will only be administered according to manufacturer’s label or prescription

medication order and permission form will be necessary*