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St. Paul Lutheran School

1578 CR 211

Giddings, TX  78942

979-366-2218

Prescription Medication Form

2016 - 2017

I request and hereby give permission to school personnel to give the prescription to my child named below as requested by the physician.

________________________________                ________________________________

Child’s Name                                                        Date of Birth

________________________________                ________________________________

Telephone Number                                                Parent Signature

Physicians’s Statement

________________________________                ________________________________

Child’s Name                                                        Date

In order that this school child remain in optimum health and to help maintain maximum school performance, it is necessary that the following medication be given during school hours.

________________________________                ________________________________

Name of Medication                                                Dosage to be given (amount)

Form of medication: ☐ tablet     ☐ capsule     ☐ liquid     ☐ inhalation     ☐ injection

________________________________                ________________________________

How often and what times                                        Purpose

Side effects:

______________________________________________________________________

_________________________________        ________________________________

Printed name of physician                                        Physician’s signature

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