PERMISSION FORM FOR ADMINISTRATION OF MEDICATION
IN SCHOOLS

Name of Child:____________________________ Date of Birth_________

School:___________________________________Grade:______________

DIAGNOSIS:_________________________________________________

NAME OF MEDICATION: _____________________________________

TIME:_____________________ DOSAGE:_________________________

BEGINNING DATE:__________________ENDING DATE___________

POSSIBLE SIDE EFFECTS:_____________________________________

__________________________________________________________

________________________________________  ______________
Name of Prescribing Health Care                         Date

Phone/fax #Provider/dentist ___________________________________

I request that the principal or his/her designee administer my child the medication as directed above. I authorize the release and exchange of health information from the above care provider to Yellowstone City-County Health Department and Morin School. A health care provider's name will be required for all prescription medications.

________________________________   _________  
Signature of Parent/Guardian                 Date                         

Phone ______________ Emergency Phone Number ____________

PARENT NOTE

Please note: Student's medication must be in the prescription bottle or the original bottle for over the counter medication. Refer to medication policy.

REQUEST FOR SELF-ADMINISTRATION OF MEDICATION IN SCHOOLS

Name of Child:__________________________ Date of Birth__________

School: ______________________________ Grade: __________

DIAGNOSIS:__________________________________________________

NAME OF MEDICATION: __________________________________________

TIME: ______________________

DOSAGE:____________________________

BEGINNING DATE: _________________ ENDING DATE: ______________

POSSIBLE SIDE EFFECTS: ____________________________________________________________

____________________________________________________________

NAME OF PRESCRIBING HEALTH CARE PROVIDER:__________________

I request that the principal or his/her designee allow my child to take the medication as directed above. I authorize the release and exchange of health information from the above health care provider to Yellowstone City-County Health Department and Morin School.

____________________________________  ____________  _________
Signature of Parent/Guardian                      Date                Phone

_______________________
Emergency Phone Number

_______________________________________________  ___________
Name of Prescribing Health                                           Date

Care Provider Phone#/ _________________ Fax# ________________

PARENT NOTE

Please note: Student's medication must be in the prescription bottle or the original bottle for over the counter medication. Refer to medication policy.