Consent Form for Medication
in the Saint Louis Public Schools

Note to Parents/Guardians:

The Saint Louis Public School policy requires that all students who need medication during school hours
must do the following:

1. Present a written consent form signed by a person with prescriptive authority and the parent or guardian.
2. Bring the medication in the original prescription bottle, properly labeled by a registered pharmacist
   as prescribed by law.

This includes all prescription and over the counter medications.

Name of student ________________________________

Date of Birth ______________________ School ______________________________

To be completed by doctor or nurse practitioner

Diagnosis _________________________________________________________________

Name of medication & dosage

Dosage and specific time(s) to be given at school

Length of time (not to exceed one school year)

Are there any restrictions    Yes_______    NO ________     If YES, specify _________________________

Printed name of Prescriber ________________________________________   

Signature of Prescriber ___________________________________________

Date ____________   Prescriber phone number ________________________

To be completed by parent

I, ____________________________ , give permission for my child to receive the above
medication as requested.

Parent/Guardian Signature __________________________________ Date_____________

Home Telephone __________________

Work Telephone ___________________

Emergency Telephone ______________