THE WILSON SCHOOL
AUTHORIZATION TO GIVE
PRESCRIPTION OR OVER-THE-COUNTER MEDICINE
(GOOD FOR ONE WEEK ONLY)

In the event it is absolutely necessary to give medication, we must have written permission from the parent. This form must accompany medication. More forms are available from the front office.
Name of Child
Date
Dr.'s Name
Medication
Reason for prescription
Amount to be given
To be given at
To be given on M    T    W    TH    F
Special instructions
Side effects
School location of medicine
 
Parent Signature
 
For School Use Only
Day: M    T    W    TH    F
Date:
Time:
Intl.: