Grace Lutheran School

1815 E. 9800 S.
Sandy, UT 84092
572-3793

PARENTAL RELEASE FOR ADMINISTRATION OF MEDICATION

In order for our son/daughter (grade: )

to participate in the regular school program, our physician has recommended that medication be administered. I
hereby grant permission for properly designated school personnel to administer medication to my child.

signature of parent or guardian

date

telephone number

MEDICATION DOSAGE INFORMATION

MEDICATION MUST BE PROVIDED BY PARENT TO SCHOOL
OFFICE IN ORIGINAL LABELED CONTAINER.

Name of medication:

Dosage:

Approximate time(s) to be administered:

(If prescription) Name of physician prescribing medication:

Physician’s telephone number:

PLEASE NOTE: This form must be on file in the school office before school can
administer any medication (prescription or over-the-counter.) ALL
MEDICATIONS must be administered by the office. In the interest of the safety of
your child and other students, please DO NOT send medication with your child (i.e.
in lunch box, pocket, etc.) Thank you.