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Medication Form for the School Nurse



Dear Parents; 

To safeguard the transportation of medication to and from school, all prescription and over the counter medication should be brought into the nurse clinic by a parent or guardian. Students are not permitted to carry any medication without a physician's statement in writing. Any unused medication unclaimed by the parent by the last student day of school will be destroyed. 

FDA approved medication at school must include: 

For over the counter medication- it must be in the original package with the dosing information present. The nurse can only give the dose listed on the package label. If your medical provider has ordered your child to take more than the dose on the package label it would be considered a prescription dose. The school nurse will need a prescription order from your medical provider. 

For prescription medication- it must be in a prescription bottle with the most current dosing information and the student's name on the label. School must be notified immediately if there is any change in the use of the prescribed medication. 



I request that the medication described below be administered to my child/ward at the times specified during the school day. I will give the nurse the medication in its original container or current prescription bottle. 

I understand that a parent or guardian will transport all medication to and from school. 

Medications must be picked up by the last day of school, or medications will be discarded. 

I understand that a separate form must be completed for each medication. 

This request is in effect for one school year and must be renewed annually or whenever there is a change in medication. 

I understand that this medication will be administered to my child only by authorized staff members and will be kept in a secure location within the school nurse clinic. 

I give permission for the school nurse and designated school personnel caring for my child for this form to be shared with school personnel per FERPA guidelines. I release and agree to hold the Board of Education, its officials, and its employees harmless from any and all liability for damages or injury resulting directly or indirectly from this authorization.

Student's Namerequired
First Name
Last Name
Is this Prescribed or Over-the-Counter?required
Parent or Guardian's Namerequired
First Name
Last Name