Augusta School District Over-the-Counter Medication Consent Form

Student Name:*

First NameLast Name

Birthdate:*

Date

School:*

Do you grant permission to the Augusta School District to administer over-the-counter medications that you provide if/when needed to your student?*

YesNo

If yes, please select which over-the-counter medication(s) you will provide, and that you allow to be dispensed to your student by authorized school personnel.

As the parent/guardian of this student, I give the Augusta School District permission to administer the above selected over-the-counter medications that I will provide to the appropriate office. School personnel will notify the parent/guardian via email if/when medication is dispensed. I also agree to keep the school district aware of any changes in medication(s) or health concerns of my child.

If I have indicated "No," I do not authorize any adminstering of over-the-counter medication by school personnel.

Parent/Guardian:*

First NameLast Name

Parent/Guardian Phone Number:*

Parent/Guardian Email:*

Parent/Guardian Signature*

Date Signed:*

Date

Augusta School District Over-the-Counter Medication Consent Form

Student Information

Medication Consent Information