WILSON COUNTY SCHOOLS

James M. Davis , Director of Schools

351 Stumpy Lane

Lebanon, TN  37090

MJHS Phone:  615-758-5606

MJHS Fax:  615-758-5645

 

PARENTAL CONSENT FOR

OVER-THE-COUNTER MEDICATION

 

The Wilson County Board of Education requires the following information when children need over-the-counter medication at school.  This form must be completed and signed by a parent/guardian before medication will be accepted.

 

 

Student’s name:  _________________________________________

              Last                               First                        MI

______
DOB

_____

Grade

_______________________________________________

_______________

__________

Address

School

Teacher

Medication

Dosage/Time

Competent to self-administer medication with assistance   Yes                   No

Dates to Administer:      From                                                     To:

Side Effects:

Allergies:

Doctor’s Name

Phone

Emergency Contact:

Name

Phone                                      Cell

Name

Phone                                      Cell

 

 

Parent/Guardian signature _____________________________ Date_____________  Daytime Phone ____________