Eva Gordon Elementary

Medication Permission Form

Student Name _______________________________ Teacher _____________________

Address ________________________________________________________________

Birthday __________________ Sex ______ Social Security # _____________________

The following may be given to my child as needed: Please circle yes or no

(1) Tylenol – for pain (headache, cramps) yes no

(2) Pepto Bismol – stomach pains or diarrhea yes no

(3) Cough Drops – cough or sore throat yes no

(4) Toothache Medicine – toothaches yes no

(5) Moisture Drops – dust or particles in eyes yes no

(6) Benadryl liquid – severe bites, stings, allergic reaction yes no

(7) Benadryl cream – bites, stings yes no

ALLERGIES: Does your child have allergies to food or medicine? If yes, please list them in the spaces provided.

FOOD: _______________________ MEDICATIONS: _____________________

_______________________ _____________________ _______________________ _____________________

Does you child have any of the following conditions? Please circle yes or no

(1) Diabetes yes no Medication: ___________________

(2) Asthma yes no Medication: ___________________

(3) Sickle Cell yes no Medication: ___________________

(4) Seizures yes no Medication: ___________________

(5) Fainting spells yes no Medication: ___________________

(6) Bleeding disorder yes no Medication: ___________________

(7) Attention Deficit or Hyperactive yes no Medication: ___________________

List any other medical conditions or problems your child has: ______________________

________________________________________________________________________

Name of Child’s Doctor: ___________________________________________________

In case of EMERGENCY notify:

_______________ Home # ___________Work #____________ Cell # ______________

Signature: _______________________________________ Date: __________________