________________________________ ___/___/____ _________________ ___/___/___
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 medication, directions for use, and date.
- Authorization is renewed annually and immediately when the parent notifies the school that changes are necessary.
______________________ __________ ______________________ ________________
Medication/Health Care 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, instructions, and written record kept. Special considerations are noted above. The information is confidential except as provided to the Family Education Rights and Privacy ACT (FERPA). I agree to coordinate and work with school personnel and prescriber 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.
____________________________________ _____/_____/_____
Parent’s Signature Date
____________________________________ _______________________
Parent’s Address Home Phone
____________________________________ _______________________
Additional Information Business Phone
___________________________________________________________________________
____________________________________________________________________________
Authorization Form
(January 17, 2005; March 21, 2011; January 19, 2015; August 19, 2019)