Student Medication Form This form is available when pre-registering students for the school year and only needs to be filled out for applicable students. You can not include multiple children on the same form submission. Dear Parents: The Indiana State law requires that schools observe certain regulations in administering medication to pupils. Written permission of parents and/or physician is required for all medication. In order to administer medicine to your child, the following procedures must be followed: 1. Over-the-counter medication such as Ibuprofen or Acetaminophen for headaches requires written/verbal permission from the parent or guardian to the administering staff. The school has a limited supply of over-the counter medication under lock and key. 2. Prescription medications must be in the original container stating the amount of medication, the hours of administration, and the period of time medication is to be continued. The label will meet the requirements for physician’s signature; however, the parent must either complete and sign the Student Medication Permit or send in a permission note with the student’s name, medical condition, medication time and amount to be given, and accept legal responsibility for safe arrival of the medication to the school. 3. Send only the amount of medication needed for one day at a time for the student. (An exception to this would be a student on medication daily for a chronic disease. That student may bring a week’s supply in a bottle with the prescription label. ) Name of medication must be on the bottle. *Inhaler Self-Administration permission forms are available in the office. These must be filled out and on file in the office.Student Name First Last GradeCondition/Ailment/GeneralMedicationTime to be Given Hours : Minutes AM PM AM/PM Amount to be GivenParent/Guardian PhonePlease list the best contact number to be reached during school hours. Parent/Guardian SignaturePermission for the Bethlehem Lutheran School staff to administer above stated medication