Code No. 507.2E2

Page 1 of 2

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.

Code No. 507.2E2

Page 2 of 2

Parental Authorization and Release Form for the Administration

of Prescription Medication to Students

/ /

Parent's Signature Date

Parent's Address Home Phone

Additional Information Business Phone

Authorization Form