_____________________________ ___/___/___ _________________ ___/___/___
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______________
