Medical Release Form

Child's Name:

Grade:

Date of Birth:

Guardian's Name:

Phone:

Email:

Doctor's Name:

Doctor's Phone:

Doctor's Address:

Preferred Hospital:

Non Routine Over the Counter Medication
I give my permission to the school nurse or authorized persons to give my child the following medication when needed:
(Indicate for each medication listed)

Acetaminophen (Tylenol) Children's Liquid Tylenol, children's chewable Tylenol or Tylenol 325/S00mg tablets:

Ibuprofen (Advil, Motrin) Children's liquid ibuprofen or 200mg tablets:

Cough drops 1 every 3-4 hours: cough, sore throat

Is your child allergic to any medication?

Does your child require dye free medication?

Is your child able to swallow pills?

Prescription medications to be given at school:
The medication must be in an original pharmacy container with a pharmacy label listing the child’s name, the name of the medication, the dosage, and the time to be given.

Medication:

Dosage:

Time of day to be given:

Diagnosis:

Medication:

Dosage:

Time of day to be given:

Diagnosis:

Signature:

Today's Date:

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[field id="todays_date"]