In-School Medication Parent Consent Form
Student Information
Student Name
Grade
Date of Birth
School
Medication Information
Medication Name
Dosage
Time(s) to be Given
Route (Oral, Topical, etc.)
Purpose of Medication
Special Instructions
Possible Side Effects
Parent/Guardian Consent
I authorize school personnel to administer the medication as described above to my child, and to contact the prescribing physician if necessary.
Parent/Guardian Name
Signature
Date
Phone Number
Emergency Contact Name
Emergency Contact Phone
Physician Authorization (if required)
Physician Name
Phone Number
Signature
Date