Medication Authorization Form

AUTHORIZATION OF STUDENT MEDICATION To the Principal of

Date:

I, the parent/guardian of:

DOB:

would like to request that medication be given to my child at school according to the directions specified below by my family doctor. I also release any and/or all school personnel from any liability that could be brought about by administering this medication as requested here by my child’s physician. I understand this form is valid only with the physician’s signature. I also authorize the nurse and the physician to communicate sufficiently to ensure safe administration of the medication in the school setting.

Parent/Guardian Name (please print)

Parent/Guardian Signature

In accordance with the request of the parent whose name is listed above, I request the following medication(s) be given to the above named student by school personnel at school, during regular school hours.

Diagnosis 1 2 3

Medication to be given

Dosage (mg)

Time to be Given

Yes

No

Would this medication be dangerous if taken by any person other than the one for whom it was prescribed?

Yes

No

Should this medication be kept in a locked container?

Yes

No

Does this medication require storage under refrigeration?

Yes

No

Would this medication prevent the child from participation in field trips or other school activities?

Yes

No

Is any of this medication specifically for seizure control?

Yes

No

Do you recommend that this medication be kept on his person at all times? (i.e. asthma inhaler and/or epi-pen for severe allergy or other severe allergic condition).

Any specific instructions to the school:

Physician’s Name (please print) Principal

Physician’s Signature Date

School Nurse

Phone Date

School person to give medication

Date trained by School Nurse

Alternate person to give medication

Date trained by School Nurse

THIS AUTHORIZATION IS IN EFFECT FOR ONE YEAR. A NEW FORM MUST BE SIGNED BY THE DOCTOR EACH YEAR.