_________________________________ ___/___/___ _________________ ___/___/___
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/Health Care Dosage Route Time at School
Administration instructions
Special Directives, Signs to Observe and Side Effects
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Discontinue/Re-Evaluate/Follow-up Date
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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.
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Parent's Signature Date
Parent's Address Home Phone
Additional Information Business Phone
Authorization Form