Tipton Academy

Medication  Permission  Form   (For  all  over-­‐the-­‐counter  and/or  prescribed  medications)    

Student:___________________________________________________________ Date  form  received:________________________________  
Date  of Birth:__________________________________ Grade/Teacher:_________________________________________________________  

To  be  completed  by  the  physician:  

Name  of  Medication:______________________  Reason  for  medication  (optional):_____________________________________   Form  of  medication/Treatment:   _______Tablet/capsule      _______Liquid      _______Inhaler      _______Injection        _______Nebulizer      _______Other     Start:     Date  form  received:________________________________________Other  dates:__________________________________   Stop:     End  of  school  year:________________________________________  Other  date/duration:________________________   Restrictions  and/or  important  side  affects:          ______None  anticipated   ______Yes  (describe  below)    
  Special  storage  requirements:      ______None          ______Refrigerate      ______Other:_______________________________________   The  student  is  both  capable  and  responsible  for  self-­‐administering  this  medication:   ______Yes            ______Yes-­‐Supervised            ______Yes-­‐Unsupervised   Physician  name:__________________________________________________________________________________________________________   Address:______________________________________________________________________________Phone:____________________________   Date:__________________________Signature:_________________________________________________________________________________  

To  be  completed  by  the  parent/guardian:  

I  request  that  (student  name)_____________________________________________________________________received  the  above   medication  at  school  according  to  school  policy.   I  request  that  (student  name)_____________________________________________________________________be  allowed  to  self-­‐ administer  the  above  medication  at  school  according  to  school  policy.     Date:____________________Signature:_________________________________________________________Relationship:______________