507.02E2 - 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 special health services are administered following these guidelines:

• Parent has provided a signed, dated authorization to administer prescription medication and/or provide special health services listed. Electronic signatures meet the requirement of written signatures.
• The prescribed medication is in the original, labeled container as dispensed or the .
• 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                                                    Date

 

And credentials (when indicated for health service delivery)

 

                                                                                                                                   
Parent/Guardian Signature                     Date

 

_______________________________________             __________________________
Parent/Guardian address                                                                                    Home phone

 

                                                                                                            /            /          
Parent's Signature                                              Date

 

                                                                                                                                   
Parent's Address                                                Home Phone

 

                                                                                                                                   
Additional Information                                     Business Phone

                                                                                                                                               

                                                                                                                                               

                                                                                                                                               
Authorization Form