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Non-Prescription Medication Form

Download/Print Copy of Non-Prescription Medication

Belgrade District School Permission For Non-Prescription Medication To Be Taken At School

Download/Print Copy of Non-Prescription Medication

  1. Name of Student
    • Grade
    • Teacher
    • Mother's Daytime Phone
    • Father's Daytime Phone
  2. Name of Medication
    • Purpose of Medication
    • Time of Day or How Often Medication May Be Taken
    • Possible Side Effects
  3. Anticipated Number of Days Medication Needs To Be Taken At School
    • Additional Instructions

 

I hereby give my permission for [student's name] to take the above medication at school as stated.  I understand that it is my  responsibility to furnish this medication.

  • Signature of Parent or Guardian
  • Date