Muenster ISD Medication Permisssion Form            

MUENSTER ISD  

Date form received by the school: ______________________________

Student: ____________________________________________Date of Birth: _________________

Grade: _______ Teacher/Class____________________________________________________

TO BE COMPLETED BY THE PHYSICIAN OR AUTHORIZED PRESCRIBER: (If a prescription medication)

Reason for medication: ___________________________________________________________________

Name of medication: _____________________________________________________________________

Form of Medication/Treatment:

___Tablet/capsule  ____Liquid  ___Inhaler  ___Injection  ___Nebulizer  ___Other _____________

Instructions (Schedule and dose to be given at school): __________________________________________

   Start:  ___Date from received      Other date: ____________________________

   Stop:  ___End of school Year      Other Date/Duration______________________

   For episodic/emergency events only ____________________________________

Restrictions and/or important side effects:  None anticipated_________   Yes___________ Please describe:

Special storage requirements:   None__________   Refrigerate___________  Other ___________

This student is both capable and responsible for self-administering this medication: 

No______  Yes______

Supervised__________  Unsupervised____________

This student may carry this medication:  No__________   Yes___________

Please indicate if you have provided additional information: Back of this form____   As an attachment____

Date:____________________ Physician’s Signature: ____________________________________

   Physician’s Name: _________________________________________________

   Address: _________________________________________________________

   Phone Number: ___________________________________________________

TO BE COMPLETED by Parent/Guardian:  (both Rx and OTC)

I GIVE PERMISSION FOR  (Name of Child) ________________________________________________

to receive the above medication at school according to standard school policy.  I understand that the medication must be in its original container.