Student’s Name (Last), (First) (Middle) Birthday School Date
I request the above-named student (Parent/Guardian initial all that apply)
______ Carry and complete co-administration of prescribed medication, when competency has been demonstrated to licensed health personnel working under the auspices of the school. In accordance with
applicable laws, students with asthma, airway constricting diseases, respiratory distress or students at risk of
anaphylaxis who use epinephrine auto-injectors may self-administer their medication upon the written approval
of the student’s parents and prescribing licensed health care professional regardless of competency. The
information provided by the parent for medication administration is confidential as provided by the Family
Education Rights and Privacy Act (FERPA) and any other applicable laws. I agree to provide safe delivery of
the medication to and from school and to pick up remaining medication at the end of the school year or when
medication is expired. If the students abuses the self-administration policy, the ability to self-administer may be
withdrawn by the school or discipline may be imposed, after notification is provided to the student’s parent.
Prescribed Medication Dosage Route Time at School
______ Co-administer, participate in planning, management and implementation of special health services at
school and school activities after demonstration of proficiency to licensed health personnel working under the
auspices of the school. The information provided by the parent for health service delivery is confidential as
provide by the Family Education Rights and Privacy Act (FERPA) and any other applicable laws. I agree to
coordinate and work with school personnel and the prescriber (if indicated) when questions arise. I agree to
provide safe delivery of the student’s equipment necessary for health service delivery to and from school and to
pick up remaining equipment at the end of the school year.
Special Health Services Delivery:
Procedures for abandoned medication disposal shall be in accordance with applicable laws.
Prescriber’s Signature Date And credentials (when indicated for health service delivery)
Parent/Guardian Signature Date
Parent/Guardian address Home Phone
NEW***Exhibit 507.02-E(4): Administration of Medication to Students – Parental Authorization and Release Form for the Administration of Voluntary School Stock of Over-the-Counter Medication to Students
Student’s Name (Last), (First) (Middle) Birthday School Date
The district supplies the following nonprescription, over-the-counter medications that are listed below. Generic brands may be substituted,
- Acetaminophen administered per manufacturer label
- Throat Lozenges administered per manufacturer label
Voluntary school stock of nonprescription, over-the-counter medications are administered following these guidelines:
- Parent has provided a signed, dated annual authorization to administer the nonprescription, over-the-counter medication(s) listed according to the manufacturer instructions. Electronic signature meets the requirement of written signature
- The nonprescription, over-the-counter medication is in the original, labeled container and dispensed per the manufacturing label.
- All other nonprescription, over-the-counter medication not listed will require a written parent authorization and supply for the over-the-counter medication.
- Supplements are not nonprescription, over-the-counter medications approved by the Federal Drug Administration and are NOT applicable.
- Nonprescription, over-the-counter medications approved by the Federal Drug Administration that require emergency medical service (EMS) notification after administration are NOT applicable.
- Persons administering nonprescription, over-the-counter medication include licensed health personnel working under the auspices of the school and individuals, whom licensed health personnel have delegated the administration of medication with valid certification who have successfully completed a medication administration course approved by the department and annual medication administration procedural skills check.
- Districts stocking the administration of voluntary stock of nonprescription, over-the-counter medications, collaborate with licensed health personnel to develop and adopt a protocol shared with the parent to define at a minimum:
- When to contact the parent when a nonprescription medication, over the counter medication is administered;
- Documentation of the administration of the nonprescription, over-the-counter medication and parent contact;
- A limit to the administration of a school’s stock nonprescription, over-the-counter medications that would require a prescriber signature for further administration of a school’s nonprescription, over-the-counter medications for the remaining school year;
- The development of an individual health plan for ongoing medication administration of health service delivery at school.
I request that the above-named student receive the voluntary stock nonprescription, over-the-counter medications supplied by the school in accordance with the district guidelines and protocol.
Parent/Guardian Signature Date
Parent/Guardian address Home Phone
