_________________________________ ___/___/___ _________________ ___/___/___
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
