Archdiocese of Galveston-Houston Health Manual
Revised January 2018
30d
MEDICATION PERMISSION FORM
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 may refuse to give the medication
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 Incarnate Word Academy, its servants, agents, and employees including, but not limited
to 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 Incarnate Word Academy, its agents, servants, or
employees, including, but not limited to 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:
Type of Medication
Name of Medication and Strength
Prescription Non-Prescription
Date to Begin Medication Date to End Medication Time to be Given 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
Route (ex: oral, nasal)
Physician’s Signature Physician’s Printed Name Office Phone Date
click to sign
signature
click to edit
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