School District No. 9 P. O. Box 1280 East Helena, M



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East Helena Public Schools

School District No. 9

P.O. Box 1280 * East Helena, MT. 59635


Superintendent/Administration Office (406) 227-7700

Eastgate Elementary School (406) 227-7770 * Radley Elementary School (406) 227-7710

East Valley Middle School (406) 227-7740

“Success For All”




Medication Permission Form


Student’s Name __Dylan Nguyen ________________________________


School _EVMS_______ Grade __6_____ Teacher ____________________
Diagnosis _____________________________________________________
Medication ____________________________________________________
Time ___________________ Dosage ______________________________
Special instructions _____________________________________________

_____________________________________________________________


Possible side effects ____________________________________________

_________________________ _____________________

Physician’s Signature/Date Parent’s Signature/Date

From time to time, it may be necessary for your child to take prescription medicine for treatment of an illness. Medication ordered to be taken less than 4 times a day can and should be taken at home. However, if medicine must be taken 4 times a day, or at a specific time scheduled during school hours, the school nurse, as mandated by state law, may dispense medications ONLY WITH THE FOLLOWING:



  1. Medication order signed by the physician

  2. Parental authorization, signed by the parent

  3. Original pharmacist labeled bottle


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