Student's Name (Last), (First) (Middle)___________________________________________________________ Birthday ___/___/___
School ______________________________________________________________________________________ Date ___/___/___
School medications and health services are administered following these guidelines:
- Parent has provided a signed, dated authorization to administer medication and/or provide the health service.
- The medication is in the original, labeled container as dispensed or the manufacturer's labeled container.
- The medication label contains the student's name, name of the medication, directions for use, and date.
- Authorization is renewed annually and as soon as practical when the parent notifies the school that changes are necessary.
Medication / Healthcare ___________________________________Dosage ______________________Route __________________Time_______________
at School __________________________________________
Administration instructions:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Special Directives, Signs to Observe and Side Effects:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
__________/___________/______________
Discontinue / Re-Evaluate / Follow-up Date
Prescriber's Signature _______________________________________________________________________Date ___/___/___
Prescriber's Address ___________________________________________Emergency Phone____________________________
I request the above named student carry medication at school and school activities, according to the prescription, or other medication administration instructions, and a written record kept. Special considerations are noted above. The information is confidential except as provided by the Family Educational Rights and Privacy Act (FERPA) and any other applicable law. I agree to coordinate and work with school personnel and prescriber (if any) when questions arise. I agree to provide safe delivery of medication and equipment to and from school and to pick up remaining medication and equipment. Procedures for medication disposal shall be in accordance with federal and state law.
********************************************************************************************
PARENTAL AUTHORIZATION AND RELEASE FORM FOR THE ADMINISTRATION
OF MEDICATION TO STUDENTS
Parent/Guardian Signature ___________________________________________________________________Date ___/___/___
Parent/Guardian Address ___________________________________________________________Business Phone___________
Home Phone_____________________
Additional Information
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Authorization Form*
