PARENTAL AUTHORIZATION AND RELEASE FORM FOR THE ADMINISTRATION
OF PRESCRIPTION MEDICATION TO STUDENTS
_______________________________ _________ ____________ ___/___/___
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 dispenses or the manufacturer’s labeled container.
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The medication label contains the student’s name, name of the 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, and a 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
______________________________________________________________________
______________________________________________________________________
*Adopted: 12/13/10
*Revised: 11/12/12
*Reviewed: 09/18/17
*Reviewed: 09/12/22
