507.02 E(3): PARENTAL AUTHORIZATION AND RELEASE FORM FOR INDEPENDENT SELF CARRY AND ADMINISTRATION OF PRESCRIBED MEDICATION OR INDEPENDENT DELIVERY OF HEALTH SERVICES BY THE STUDENT
_________________________________ ___/___/___ _________________ ___/___/___
Student's Name (Last), (First), (Middle) Birthday School Date
I request the above-named student (Parent/Guardian initial all that apply)
______ Carry and complete co-administration of prescribed medication, when competency has been
demonstrated to licensed health personnel working under the auspices of the school. In accordance with
applicable laws, students with asthma, airway constricting diseases, respiratory distress or students at risk of
anaphylaxis who use epinephrine auto-injectors may self-administer their medication upon the written approval
of the student’s parents and prescribing licensed health care professionals regardless of competency. The
information provided by the parent for medication administration is confidential as provided by the Family
Education Rights and Privacy Act (FERPA) and any other applicable laws. I agree to provide safe delivery of
the medication to and from school and to pick up remaining medication at the end of the school year or when
medication is expired. If the students abuses the self-administration policy, the ability to self-administer may be
withdrawn by the school or discipline may be imposed, after notification is provided to the student’s parent.
______________________________________________________________________________________
Prescribed Medication Dosage Route Time at School
______ Co-administer, participate in planning, management and implementation of special health services at
school and school activities after demonstration of proficiency to licensed health personnel working under the
auspices of the school. The information provided by the parent for health service delivery is confidential as
provide by the Family Education Rights and Privacy Act (FERPA) and any other applicable laws. I agree to
coordinate and work with school personnel and the prescriber (if indicated) when questions arise. I agree to
provide safe delivery of the student’s equipment necessary for health service delivery to and from school and to pick up remaining equipment at the end of the school year.
Special Health Services Delivery:
________________________________________________________________________________________________________________________________________________________________________________
Procedures for abandoned medication disposal shall be in accordance with applicable laws.
____________________________________ ___/___/___
Prescriber’s Signature Date
and credentials (when indicated for health service delivery)
____________________________________ ___/___/___
Parent/Guardian Signature Date
_______________________________________ __________________________
Parent/Guardian Address Home Phone
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: October 16, 2023
Reviewed: October 16, 2023
Revised: October 16, 2023