SOUTH BURLINGTON SCHOOL DISTRICT
PERMISSION FOR MEDICATION

______________________________                    _____________________        _______________
Name of Student                                                    School                                         Grade

Medication:

Dosage:

Directions:

Reasons for Giving:



_________________________________*
Signature of Physician

_________________________________
Name of Physician (Please Print)

_________________________________
Telephone number of Physician

I hereby give my permission for student ___________________________ to take the above prescription (medication) at school as ordered.

___________________________________            _____________
Signature of Parent or Guardian                             Date

N.B.    No medication will be given at school until the school receives the completed form with the prescribed medication in a container appropriately labeled.

* Non-Prescription medication does not require a physician's signature unless it is for ongoing long-term use.