507.2E2 - Parental Authorization and Release Form for the Administration of Prescription Medication to Students

PARENTAL AUTHORIZATION AND RELEASE FORM FOR THE ADMINISTRATION OF 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 special health service listed.  Electronic signatures meet the requirement of written signature.
• The prescribed medication is in the original, labeled container as dispensed..
• The prescription medication label contains the student’s name, name of the medication, the medication dosage, time(s) to administer, route to administer and date.
• Authorization is renewed annually and as soon as practical when the parent notifies the school that changes are necessary.

                                                                                                                                             _________  
Prescribed Medication                   Dosage                         Route                           Time at School

Special Health Services and instructions, in indicated:

                                                                                                                                               

                                                                                                                                              

________________________________________________________

________________________________________________________

 

            /           /          
Discontinue/Re-Evaluate/Follow-up Date for Prescribed Medication or Special Health Services listed.

                                                                                                             /           /           
Prescriber’s Signature and credentials                               Date

(when indicated for health service deliver)

                                                                                                            /            /          
Parent's Signature                                                            Date

                                                                                                                                   
Parent's Address                                                              Home Phone

                                                                                                                                   
Additional Information                                                  Business Phone

                                                                                                                                               

                                                                                                                                               

                                                                                                                                               
Authorization Form