___________________________________ ___/___/___ _________________ ___/___/___
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 immediately 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
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Discontinue/Re-Evaluate/Follow-up Date
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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, instructions, and a written record kept. Special considerations are
noted above. The information is confidential except as provided to the Family Education Rights and Privacy Act (FERPA). I agree to coordinate and work with school personnel and
prescriber 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.
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Parent's Signature Date
Parent's Address Home Phone
Business Phone
Additional Information
