St. Paul Lutheran School
1578 CR 211
Giddings, TX 78942
Over- the- Counter Medication Form
2016 - 2017
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