Medication Consent Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Medication Consent Form

Forms need to be submitted annually.

Only ONE STUDENT per form.

ALL MEDICATIONS NEED TO BE BROUGHT TO SCHOOL BY AN ADULT - do not send them to school with your child.

Prescription medication needs physician instructions, authorization, and signature.

Over-the-counter medication must follow the manufacturer's instructions. Any alternate dosing schedule must be provided, authorized, and signed by a physician.

ALL MEDICATIONS MUST BE IN NEW, UNOPENED PACKAGING. NO EXPIRED MEDICATIONS.

Student Name

Grade *

Birth Date *

YYYY

Height *

Weight *

Current Medications *

Allergies *

Do you need to enter a non-prescription/as-needed medication?

Yes

Clear selection

Clear form

Never submit passwords through Google Forms.

This form was created inside of Holy Hill Area School District.

Does this form look suspicious? Report

Forms