Medical Release

School M edication Authorization Form To be com pleted by the child’s parent(s)/guardian(s) and kept in the school nurse’s office or, in the absence of a school nurse, the Building Principal’s office: Student’s N am e Birth Date Address Hom e Phone

Em ergency Phone

School

Grade

Teacher

To be com pleted by the student’s physician Print Physician’s N am e O ffice Address

O ffice Phone

Em ergency Phone

M edication

Dosage

Frequency

Tim e m edication should be adm inistered or under w hat circum stances

Prescription Date

O rder Date

Discontinuation Date

Diagnosis requiring m edication Intended effect of m edication M ust this m edication be adm inistered during the school day in order to allow the child to attend school or to address the student’s m edical condition? Y ES NO Expected side effects, if any Tim e interval for re-evaluation O ther m edications student is receiving

Physician’s S ignature_______________________________Date__________ Parent/Guardian S ignature__________________________ Date__________