| MEDICATION PERMISSION AND EMERGENCY FORM PERRY PUBLIC SCHOOLS StudentName_____________________________Teacher_____________ Parent having legal custody or the legal guardian. Name______________________________________Phone____________ Home address_____________________________________________ Daytime business address and phone __________________________ ________________________________ Name of parent if other than above________________________________ Daytime home address and phone_____________________________ ________________________________ Daytime business address and phone ________________________ ________________________________ Relative or neighbor to call in case of emergency: Name ________________________________Phone______________ Family or student's physician Name ________________________________Phone _____________ I hereby authorize the schol nurse, a school administrator, or a designated school employee to administer prescription medication to Name ___________________________________________________ Name of medication________________________________________ When medication should be given _____________________________ Designate amount to be given ______________________________ I hereby authorize the school nurse, a school administrator, or a designated school employee to administer nonprescription symtomatic medication to Name ___________________________________________________ Name of medication ________________________________________ When medication should be given _____________________________ Designate amount to be given ________________________________ Is this child taking any other medication on a regular basis? Yes _______ No _______ If yes, name of medication and purpose__________________________ _____________________________________ It is ___ is not___ necessary that I be called before the medicaiton is administered. Signed _______________________________ Date ________________ Parent/ Guardian |