Parent Permission for
Administration of Non-prescription Medication
(To be returned to the School Nurse)
I hereby give my permission for:
Name of Student_____________________________________________________
in grade _______ at the Stamford Elementary School to take:
Medication_______________________________________ Dosage___________
Directions_________________________________________________________
Reason for Giving__________________________________________________
Parent/Guardian Signature___________________________________________
Date____________________________________________________________
No non-prescription medication will be given at school until the school receives this completed form with the medication provided in its original container.
All medicine brought into the school must be kept in the School Office during school hours.
Date Received_________________________________
Signature of School Nurse________________________________________
