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Prescription Medication Order and Permission Form

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  • The school nurse must have this completed form before medication will be given at school.
  • 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.
  • A parent/adult must bring the medication to school in an appropriately labeled pharmacy container.
  • All medicine must be kept in the nurse’s office unless the health care provider, parent and administrator have given permission for the student to keep the medication for self-administration.

__________________________________________________ _____ ____________

Name of Child/DOB Grade Date


Medication Order:

Medication ______________________________________Strength_____________________

Dosage/Route/Time __________________________________________________________

Start Date _________________________ End Date _____________________________

Reason for medication _________________________________________________________

Healthcare Provider Signature _________________________________________________


Parent’s permission for:

  • Health care provider may share information

I give permission for _____________________________________ (health care provider) to share information with

School nurse/s, _____________________________RN, concerning my child’s medication(s).

  • Medication to be given at school

I give permission for the medication prescribed above to be given to my child at school by the school nurse or

nurse’s designee.

Parent or Guardian Signature __________________________________________________