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.