Archdiocese of San Antonio

Catholic Schools Office

MEDICATION PERMISSION REQUEST FORM

According to the policies of the Archdiocese of San Antonio, students are not allowed to carry medication on their person, including non-prescription medications. (The only exception is that, by physician direction, a student may be allowed to carry and self-administer inhaler medication). Medications will be maintained and dispensed by appointed school health coordinators. The following steps must be taken before a student is allowed to take medication at school:

1.         Parent/guardian must present this completed consent form to the school

2.         Parent/guardian must bring the medication in the original prescription bottle, properly labeled

by a registered pharmacist as prescribed by law.

Medication may be given by school personnel provided that the prescribing health care provider completes this form.

Name of student: _____________________________________________________Grade: ___________

Date of birth: ___________________________School: ________________________________________

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TO BE COMPLETED BY HEALTH CARE PROVIDER

Medication#1_________________________________________________________________________

Name Strength Dose Time (at school) Route

Medication#2_________________________________________________________________________

Name Strength Dose Time (at school) Route

Medication#3_________________________________________________________________________

Name Strength Dose Time (at school) Route

Allergies: _____________________________________________________________________________

Special instructions: ___________________________________________________________________

____________________________________________________________________________________

___________________________________ ____________________________________ ____________

Printed Name of Health Care Provider                          Signature of Health Care Provider                 Date

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TO BE COMPLETED BY PARENT

I, ____________________________________________, request that my child be given the above medication as directed.            (Printed Name)

Signature of parent/guardian: __________________________________________Date:______________

Telephone:(Home) ___________________(Work) _________________ (Mobile) __________________