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

Administration of Medication to Students-Parental Authorization and release for the Administration or Special Health Services 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 the health service. Electronic signatures meet the requirement of written signatures.
• 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:

                                                                                                                                                                                                             

Administration instructions

                                                                                                                                                                                                             

Special Directives, Signs to Observe and Side Effects

                                                                                                                                                                                                                                                                                                                                                                                                         

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

 

 
Approved:  7/17/23                      Reviewed:     11/16/2020        Revised: 7/17/23