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
