Parent/Guardian Consent for Medication Administration

Parent/Guardian Consent for Medication Administration
Student's Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Grade*
School*
Parent/Guardian Name*

First NameLast Name
Parent/Guardian Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian Email Address*
example@example.com
Please indicate the type of medication your student will be taking at school.*

Non-Prescription/Over the Counter MedicationPrescription MedicationBoth
Non-Prescription/Over the Counter Medication

Non-prescription (over-the-counter) medication will only be administered upon receipt of parent/guardian written consent.
Verona Area School District stocks basic over-the-counter medications. These medications may be administered, as needed, to your student by an authorized staff member with written parental or guardian consent.
I give permission for Verona Area School District authorized staff to administer the following medications, according to package instructions, to my student as needed.
Acetaminophen (ie, Tylenol)*

YesNo
Ibuprofen (ie, Motrin, Advil)*

YesNo
Antacids (ie, Tums, Rolaids)*

YesNo
Hydrocortisone Cream (ie, Cortizone-10)*

YesNo
Other Non-Prescription/Over-the-Counter Medication sent from home.*
*Non-prescription/over-the-counter medication sent from home must be in the original container or packaging with the student's name written on the container and unexpired.
Prescription Medication

Prescription medication will only be administered upon receipt of parent/guardian consent AND written instructions from the prescribing provider. Medication must be in the original pharmacy-labeled bottle, include the student's name, correct dosage, pill description, administration instructions, and be unexpired. If a medication order changes, parent/guardian is responsible for providing a new properly labeled bottle.
I give my permission for school personnel to administer the following medication(s) as directed and to communicate with medical provider(s) if necessary.
Prescription Medication(s) to be administered at school
Prescribing Doctor's Name
Clinic Name and Address
Clinic Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Clinic Fax Number
Please enter a valid phone number.Format: (000) 000-0000.
I agree to hold Verona Area School District, its employees and agents who are acting within the scope of their duties harmless in any and all claims arising from the administration of medication as described above at school. I hereby give permission to the school nurse to contact the prescribing provider as needed. I give consent for this information to be shared with relevant staff. I agree to contact the school nurse if any changes occur with the above request.
Parent/Guardian Signature*

Clear
Should be Empty:

Parent/Guardian Consent for Medication Administration

Non-Prescription/Over the Counter Medication

Prescription Medication