Consent for admin

Office of Health Services
Consent for Administration of Approved Discretionary Medications and
Health Contact Information
Student Name:______________________________________________________ Date of Birth:___________________
School:_______________________________________________ Grade /Teacher:______________________________
Allergies (include medication allergies): ______________________________________________________________
List all medications your child receives on a regular basis: _______________________________________________
__________________________________________________________________________________________________ Medical/Health Problems: Check all that apply
Other (describe) ____________________________________ Is there a health problem that would prevent full participation in the school program or physical education program? Yes Describe:____________________________________________________________________
I would like the following medication(s) made available to my child: (please check)
For Headache/Fever/Burns/Earache/Muscle Aches/Pain/Menstrual Cramps
For Upset Stomach
(age 12 and older/age 9 for menstrual cramps) (like Tums)
For Mild Allergic Reactions
For Coughs/Sore Throats For Diaper Rash
I do not want any medication given to my child in school.
Contact Information
Parent/Guardian 1 Name: __________________________ Parent/Guardian 2 Name: _____________________________ Parent/Guardian 1 Home Phone: ____________________ Parent/Guardian 2 Home Phone:________________________ Parent/Guardian 1 Cell: ____________________________ Parent/Guardian 2 Cell: _______________________________ Parent/Guardian 1 Work: ___________________________ Parent/Guardian 2 Work: _____________________________ Parent/Guardian 1 EMAIL: __________________________ Parent/Guardian 2 EMAIL: ____________________________ Parent/Guardian Home Address: ________________________________________________________________________ Persons to whom student may be released other than parent:
Name: ____________________________________________ Phone Number(s):_________________________________
Name:_____________________________________________Phone Number(s):_________________________________
Do you need assistance in obtaining health insurance for your child?

I understand that the above medications I have checked will be administered by the Registered Nurse/School Nurse in
accordance with established protocols developed by the Chief Physician of School Health Services for the Baltimore County
Department of Health and the Coordinator of Health Services for Baltimore County Public Schools. I understand that generic
equivalent of medications may be used. My signature authorizes the release of my child to the persons listed on this page.

_________________________________________________ ________________________________________________
Signature of Parent/Guardian/Eligible Student

Towson, Maryland 21204 Baltimore, Maryland 21212
Annual Consent for Administration of Discretionary Medications
and Health Contact Information
Dear Parent or Guardian:
On the reverse side of this letter is a form that provides the school nurse with updated
health information on your child, a list of persons to be contacted in the case of an illness
or injury and a section to indicate your consent for the administration of certain
nonprescription medications which are available, at no charge, for all students. This form
must be filled out each school year.

The nonprescription medication program (called Discretionary Medications) is designed to
alleviate minor discomforts and to prevent unnecessary early dismissals from school.
These medications are approved by the Chief of School Health Services, Baltimore
County Department of Health, and the Coordinator, Office of Health Services, Baltimore
County Public Schools.
Your consent must be obtained before any medication is given to your child. Only the
Registered Nurse/School Nurse may administer these medications in accordance with
established protocols. The consent form lists the medications which may be available.
Please complete the consent form, and return it to the school nurse.
Approved discretionary medications are intended for occasional use only. If your
child requires any prescription or nonprescription medication on a regular basis,
you must obtain a written order from your health care provider and supply the

If you have any questions or would like further information, please contact your school
Bureau of Child, Adolescent, Reproductive and School Health Baltimore County Department of Health



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