507.02 E2 - Parental Authorization and Release Form for the Administration of Medication or Special Health Services to Students

507.02 E(2): PARENTAL AUTHORIZATION AND RELEASE FORM FOR THE ADMINISTRATION

OF MEDICATION OR SPECIAL HEALTH SERVICES TO STUDENTS

 

_________________________________     ___/___/___          _________________         ___/___/___

Student's Name (Last), (First), (Middle)            Birthday                         School                           Date

 

School medications and special health services are administered following these guidelines:

 

• Parent has provided a signed, dated authorization to administer prescription medication and/or provide

special health services listed. Electronic signatures meet the requirement of written signatures.

• The prescribed medication is in the original, labeled container as dispensed.

• The prescription medication label contains the student’s name, name of the medication, the medication

dosage, time(s) to administer, route to administer, and date.

• Authorization is renewed annually and as soon as practical when the parent notifies the school that

changes are necessary.

 

__________________               __________________               _________________                ____________

 Prescribed Medication              Dosage                                       Route                                         Time at School

 

Special Health Services and instructions, as indicated:

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

____/_____/_____

Discontinue/Re-Evaluate/Follow-up Date for Prescribed Medication or Special Health Services Listed

 

________________________________________________                    ____________________

Physicians Name/RX #                                                                                Date

 

_________________________________________________                  ____________________

Parent/Guardian Signature                                                                          Date

 

_______________________________________                                      ____________________

Parent/Guardian address                                                                            Home Phone

 

Additional Information 

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

Authorization Form

 

I.C. Iowa Code References Description

Iowa Code § 124 Controlled Substances 

Iowa Code § 147.107 Drug Dispensing/Supplying 

Iowa Code § 152 Nursing 

Iowa Code § 155A.4 Dispensing/Distributing Prescription Drugs - Exceptions  

Iowa Code § 280.16 Asthma - epi-pens

Iowa Code § 280.23 Student Health Services 

 

I.A.C. Iowa Administrative Code

281 I.A.C. 14 Special Health Services 

281. I.A.C 14.1 Medication Administration - 

655 I.A.C 6 Nursing 

 

Approved: January 17, 2005; March 21, 2011; January 19, 2015; August 19, 2019; October 16, 2023

Reviewed: October 16, 2023

Revised: October 16, 2023