This form is designed to assure parents and protect children in need of receiving medication during the school day or school activity appropriate handling of such needs. The general contents of the form have been reviewed by the Department of Public Instruction of the Department of Health. The School District does not in any way want to discourage parents from dispensing or supervising medication to their children at school if they are able to do so, but is assisting only as an alternative.

                                                                                Date: _________________

Student’s Name: __________________________  School Yates Primary

I hereby give my permission to the staff at Yates Primary School to dispense medication prescribed by Dr. ________________________________ for my child, beginning _______________(date); ending ______________(date)                          

Name of medication or prescription number (including drug store):

_______________________________________________________________________

Special instructions for dispensing: _______________________________________________________________________

_______________________________________________________________________

If there are any side effects of this medication, please indicate:

________________________________________________________________

___________________________________ _____________________________

Physician’s Signature_______________  Parent or Guardian________________