Note to parent/guardians:

Note to Parent/Guardians:
To comply with State Law governing the administration of medication at school, the Pendleton County
School system requires that all students who need medication during school hours do the following:
1. The parent or legal guardian must sign the written consent form for both non-prescription and prescription
medication. (The school does not provide non-prescription medication, such as Tylenol, Benadryl, etc. It is the
parent’s responsibility to send this medication to the school in the original container.)
2. The Prescription medication section of this form must be signed by the physician, and the prescription
medication sent to school in the original prescription bottle.
3. A medication form is required for each medication.
4. If there is any question about the dosage of medication the child is to receive, it will not be given unless the
parent or physician clarifies instructions.
5. The first dose of any medication must be given at home due to the possibility of allergic reaction.
6. Medication should only be taken at school when absolutely necessary; it is best to give medications at home.
Name of Student_____________________________________ Date of Birth ___________________________
Age______________ Grade_________________ School ___________________________________________
I, ____________________________ hereby request that trained, authorized staff of the Pendleton County Board of Education administer the non-prescription medication listed below to my son/daughter as directed by the physician. ____________________________________________ ____________________ ______________________ PARENT/GUARDIAN SIGNATURE TELEPHONE DATE
(For medication such as Tylenol, Advil, Benadryl, etc.) (Completed by Parent)
Name of medication:_________________________________________________________________________ Reason for Medication (illness): _______________________________________________________________ Dosage ________________________ Time to be given: ____________________________________________ Comments: ________________________________________________________________________________ PRESCRIPTION MEDICATION
(Physician Signature Required)
Name of Medication: ________________________________________________________________________
Reason for Medication: ______________________________________________________________________
Specific time(s) and dose(s) to be given at school: _________________________________________________
Method of Administration: _______oral _______IM injection_____subq. Injection______inhalation_____other
Comments: (side effects, and/or other instructions) ________________________________________________
________________________________________ __________________________________ _____________
Printed Name of Physician Signature of Physician Date



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