507.2E2 - Parental Authorization and Release Form for the Administration of Prescription Medication 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.
• 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

                   /                    /                              
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, 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.

 

                                                                                                            /            /          
Parent's Signature                                                                   Date

 

                                                                                                                                                         
Parent's Address                                                                      Home Phone

 

                                                                                                                                                     
Additional Information                                                           Business Phone

 

 

                                                                                                                                                                                   

                                                                                                                                                           

                                                                                                                                                           

Authorization Form

 

 

Approved: November 26, 2018                           
Reviewed: Aug.25, 2014, Oct. 15, 2018                
Revised: Oct. 15, 2018