507.2E2 PARENTAL AUTHORIZATION AND RELEASE FORM FOR THE ADMINISTRATION OF PRESCRIPTION MEDICATION TO STUDENTS

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 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 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, instructions, 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.

Code No. 507.2E2

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PARENTAL AUTHORIZATION AND RELEASE FORM FOR THE ADMINISTRATION 

OF PRESCRIPTION MEDICATION TO STUDENTS

 

                                    /    /   

Parent's Signature                        Date

 

                                           

Parent's Address                        Home Phone

 

                                           

Additional Information                        Business Phone

                                               

       

                                               

 

                                               

Authorization Form