Des Moines Public School District - Request for Giving Medicine at School

I give my permission for:
to receive the medication listed below at school.

I understand that I must:

1. Send the medicine to school in an original pharmacy container with a pharmacy label listing the child’s name, the name of the medicine, the dosage, and the time to be given.

2. Sign this statement.

3. Provide a written statement from the physician and parent for student self-administration of medication.

I further authorize the school nurse to contact my child’s doctor to clarify orders specifically related to giving this medication. 

This form must be renewed at the beginning of each school year if your child takes daily medication.

Medication cannot be given without parent/guardian written consent.

On the last day of school, I would like this medication to: *
 
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Signature of Parent/Guardian *
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