• Muenster ISD Medication Permission Form     HORNET       

    MUENSTER ISD  

    Permission Form for Prescribed AND/OR OTC Medication
    (printer friendly version at bottom of page)

    Date form received by the school: ______________________________

    Student: ____________________________________________Date of Birth: _________________

    Grade: _______ Teacher/Class____________________________________________________

     

    TO BE COMPLETED BY THE PHYSICIAN: (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.

    Date: ____________ Signature: ______________________________________
     
    Relationship:________________________

      

    Click here for a printer friendly copy:  Printer Friendly Version of Medication Permission Form 
     
    School Asthma Action Plan Form...for if you need to have an inhaler at school:  
Last Modified on July 24, 2017