Port Washington-Saukville School District







Name of Student:______________________________����������� Date of Birth:________________


School:_______________________________________��� Grade:_______________________


Names of Parent(s)/Guardian: _____________________________________________________


Phone: (Home) __________________________���� (Work) ______________________________


I give permission for my child to receive over-the-counter medication during school hours.


I will be responsible for:

1)      Delivery of medication in an original manufacturer�s labeled container to the school office

2)      Maintaining a sufficient supply of medication

3)      Keeping school personnel informed of changes in the medication (dosage, time)


I hereby release the Board of Education and its agents and employees from any and all liability that may result from my child taking the prescribed medication.



______________________________________��� ����������� ______________________________

����������� (Parent/Guardian Signature)������������� ������������������������������� ������������������������������� ��������������� (Date)




Name of Medication����������� Dosage����������������������� ����������� Form* ����������� Time��� ����������� Possible Side Effects

�� (Generic and Trade)��������������� (mg/cc/tsp/gtt)��������������� ��������������� (tab/cap/liq)��������������� a.m./p.m. �����������������������     




*Prior to administration of medication by routes other than oral, school personnel must contact the school district nurse for instruction.


I understand the above information may be shared by the school principal with necessary school personnel.The above request shall remain in effect through ___________________, unless parent/guardian withdraws the request in writing.�����������������������          (Date)




For School Use Only


1.        Date Received:__________________________

2.        Name of Person (s) who will administer the medication:

______________________________________________ _______________________________________________

3.        Approved by: __________________________________________________ _______________________________

(Signature of Principal) (Date)