507.2E2 - 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.

 

                                                                                                            /            /          
Parent's Signature                                                                      Date

 

                                                                                                                                   
Parent's Address                                                                        Home Phone

 

                                                                                                                                   
                                                                                                    Business Phone

Additional Information                                                             

                                                                                                                                               

                                                                                                                                                

                                                                                                                                               

Authorization Form

 

 

Approved 4/10/06                    
Reviewed 11/15/21_______                  
Revised______________