Byram Township Schools

Medication Permission Form

For Parents

______________________

           Date

__________________________ ___________________ _________________ _________________

Student Name                                             Grade & Class                           Home Phone #                 Emerg. Phone #

__________________________ ____________________ ________________ _________________

Physician Name                                           Phone Number                            Pharmacy                       Prescription #

__________________________ ______________________ ________________ _________________

Medication Name                                         Dosage & Time                         Start Med. Date                 Finish Date

___________________________________           ______________________________________________________

Condition requiring medication Re-evaluation by physician if med. is continued past finish date.

The medicine is to be furnished and delivered by me in a properly labeled pharmacy bottle.

(Please check one)

Nurse may discard empty medicine bottle ____

I will pick up medicine bottle _____

Signature______________________

(Parent/Guardian)

Date__________________________

(for School Nurse-  See P.D.R. pg._____for Reference regarding medication)