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Dear Parents,
In order to protect the health and welfare of children, Indiana rules and regulations require that schools observe certain safeguards in the administration of medication to students during school hours. In order to comply with state laws, the following procedures will be observed.
1) Prescription medications must be brought to school and kept in the pharmacys original container.
Prescription infers physicians order and approval. This includes over-the-counter drugs as well as prescription medications. Only this form (Consent for Administration of Medication) will be accepted for administration of medication at school.
2) Medication, whether over-the counter or prescribed, must be brought to school and kept in the original container and placed in the building principals office or the nurses office in a secure manner. Any medication sent to school may no longer be transported home with the student. Please refer to Health Form 1B for more information.
3) Consent to administer this medication during school hours is valid for the current school year. If at all possible, medication should be scheduled to be given at home other than school hours. Should your child require this medication on a long-term or continuing basis, we must again ask your permission each year.
4) Medication will be administered by the building administrator and/or his/her designee in the absence of the administrator.
5) Adult strength over the counter medication will not be given to students under 12 years old unless accompanied by a doctors order.

Student Name
Parent Name
Email Address
Phone Number
Date Initiated (mm-dd-yyyy)
I have read the above safeguards and give my consent for the following medication(s) to be administered to my child during school hours as prescribed:
Parent Signature
Medication Name, Dosage, Time Given
Physician Name
Phone Number
Verified By
Date (mm-dd-yyyy)
Verified Type
Please place 1 copy in students file
Attach Document (PDF, JPG, PNG, GIF, TIFF Only)

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