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St. Paul Lutheran School

1578 CR 211

Giddings, TX  78942

979-366-2218

Over- the- Counter Medication Form

2016 - 2017

Date ______________________

I am requesting and hereby give permission to school personnel to give the following medication during school hours to my child named below in order to maintain my child’s physical health and support school performance.  To my knowledge, my child has no allergy to this medication.

_____________________________________                ________________________________

Child’s Name                                                        Date of Birth

_____________________________________                ________________________________

Parent Signature                                                Telephone Number

_____________________________________                ________________________________

Name of Medication                                                Dosage

_____________________________________

Frequency (how often to be given)

Important Information for Parents/Guardians:

The medication listed above must be supplied by the parent/guardian and must be in the original manufacturer’s container with an original label containing dosage instructions.  Please do not sent OTC medications in baggies or other containers.

Please return this form to the school office along with the medication