PARENTAL AUTHORIZATION AND RELEASE FORM FOR THE ADMINISTRATION OF MEDICATION TO STUDENTS
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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.
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Prescribed Medication Dosage Route Time at School
Special Health Services and instructions, in indicated:
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Discontinue/Re-Evaluate/Follow-up Date for Prescribed Medication or Special Health Services listed.
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Prescriber’s Signature and credentials Date
(when indicated for health service deliver)
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Parent's Signature Date
Parent's Address Home Phone
Additional Information Business Phone
Authorization Form
