Revised January 2021 Archdiocese of Galveston-Houston | Catholic Schools Office, 2021-2022 36d
MEDICATION PERMISSION FORM
Catholic Schools Office
2021-2022 School Year
Archdiocese of Galveston-Houston
Student_______________________________________________________ D.O.B.__________________
School _______________________________________________________Grade____________________
Policy for students receiving medication at school whether prescribed medication or over the counter medication
approved by a physician is as follows:
Signed orders from the parent/guardian and physician must be on file
All medication must be provided in the original container
Prescribed medication with a pharmacy label that matches the written orders
All medication must be provided to the school by the parent
School personnel will review TCCB ED and Archdiocesan guidelines to ensure medication may be administered
A completed Medication Permission Form is approval for one academic school year
To be completed by the Parent/ Guardian
Does the parent want to be called before a PRN “as needed” medication is given? Yes No
Parental/Guardian Consent
I hereby request that the medication specified by the prescribing physician to be given to the above named student. I
understand that the school personnel who give the medication may not be a medically trained person. I realize that the
school does not have to agree to allow medication to be given to a student by school personnel. I understand that the
school’s agreeing to allow the medication to be given is for my benefit and the student’s benefit. Such agreement by the
school is adequate consideration of my agreements contained herein.
In consideration for the school agreeing to allow the medication to be given to the student as requested herein, I agree to
indemnify and hold harmless the Archdiocese of Galveston-Houston, its servants, agents, and employees including, but
not limited to the parish, the school, the principal, and the individuals giving the medication of and from any and all
claims, demands, or causes of action arising out of or in any way connected with the giving of the medication or failing to
give the medication to the student. Further, for said consideration, I, on behalf of myself and the other parent of the
student, hereby release and waive any and all claims, demands, or causes of action against the Archdiocese of Galveston-
Houston, its agents, servants, or employees, including, but not limited to the parish, the school, the principal, and the
individual giving or failing to give the medication.
Parent/ Guardian Signature _________________________________________Date ____________________
**Special forms are required for severe allergies and administration of Epipens, administration of diabetic medication, and self-administration and carrying of asthma medication.
To be completed by the Physician:
Name of Medication and Strength
Prescription Non-Prescription
Amount to be Given (Dosage)
For PRN state the Frequency (time between dosages of medication and maximum number in a school day
Reason medication being given
Form of Medication
Tablet Capsule Liquid Inhalant Injection Other
For additional medications use back page.
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