Archdiocese of Los Angeles
Sacred Heart School
Medication Authorization and Permission Form

Part A, B & C to be completed by a licensed Physician

Part D by parent/guardian – please print

A.   ______________________________________________________    ____________________
L     Last Name of Student                          First Name                                     Sex            Birth Date

________________________________________    ____________________________________
Purpose of Medication or Diagnosis                                 Name of Medication

_____________________    ________________________    _____________________    _______
Dosage Prescribed                    Time Schedule at School              Dose Form(tablet/liquid)          Color

__________________    __________________________________________________________
Date of Prescription           Length of Time this Medication will be Necessar

B.    Physician’s Recommendations. (check where applicable)

______  Please notify this office if patient misses medication at school.

______  Medication may have adverse effects (explain) ______________________________________

            ________________________________________________________________________

______  Special instructions and/or comments ___________________________________________

            ________________________________________________________________________

C.   Physician’s Authorization. The student for whom this medication is prescribed is under my care

_______________________________________    _____________________________________
Print Name of Licensed Physician                                 Signature of Licensed Physician

_______________________________________    ___________________    ________________             Address                                                                                Telephone                           Date

D.  Permission for Medication to be Taken During School Hours

I request that my child, ________________________________________ , be permitted to receive and to be assisted/supervised in taking the above prescribed medication at school. I will comply with the policies and procedures determined by the school district.

_____________________    ____________________________    _________________________
Date                                                        Day Telephone                                      Emergency Telephone

                                                                        __________________________________________
                                                                                                Signature of Parent/Guardian