507.04 E2 - Parental Authorization and Release Form for the Administration of Prescription Medication to Student

 

________________________________        ___/___/____  _________________  ___/___/___

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)