STUDENT PERSONNEL
Series 500
PARENTAL AUTHORIZATION AND RELEASE FORM FOR THE ADMINISTRATION OF MEDICATION TO STUDENTS
Code No.: 566E3
______________________________________ ___/___/___ _______________________ ___/___/___
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.
• The medication is in the original, labeled container as dispensed or the manufacturer's labeled container.
• The medication label contains the student’s name, name of the medication, directions for use, and date.
• Authorization is renewed annually and as soon as practical when the parent notifies the school that changes are necessary.
_________________________ _____________ ___________ _____________________
Medication/Health Care Dosage Route Time at School
______________________________________________________________________________
______________________________________________________________________________
Administration instructions
______________________________________________________________________________
______________________________________________________________________________
Special Directives, Signs to Observe and Side Effects
______ /_____ /______
Discontinue/Re-Evaluate/Follow-up Date
____________________________________ __________/________/__________
Prescriber’s Signature Date
_____________________________________ _______________________________________
Prescriber's Address Emergency Phone
I request the above named student carry medication at school and school activities, according to the prescription, or other medication administration instructions, and a written record kept. Special considerations are noted above. The information is confidential except as provided by the Family Educational Rights and Privacy Act (FERPA) and any other applicable law. I agree to coordinate and work with school personnel and prescriber (if any) when questions arise. I agree to provide safe delivery of medication and equipment to and from school and to pick up remaining medication and equipment. Procedures for medication disposal shall be in accordance with federal and state law.
(Parent's signature) ____
Parent's address _________________________________________________________
Date _______________Home Phone __________________ Work Phone ________________
Additional information
Authorized Form _____________________________________________________________
________________________________________________________________________________________________________________________________________________________
