MEDICATION AUTHORIZATION FORM

Dear Parent/Guardian,
If a student must take medication he/she should do this at home whenever possible. In the
event a student must take medication at school, proper written consent must be given to school
personnel to administer the medication. Please note the following:
No medication including prescription, over-the-counter, or herbal remedies will be administered by
school personnel or its agents until the consent forms are completed and on file with the school.
All medication must be in the original container.
All prescription medication must have a pharmacy label including the students name, correct
dosage, and time(s) to be given.
Parents are responsible for bringing medication to the school and picking up unused medication
within 10 days after the medication has been discontinued.
Students are not allowed to transport their own medication. It must be brought to school by the
parent or guardian.
School personnel may not cut tablets. If your child needs to receive half a tablet cut the tablets at
home or have the pills cut at the pharmacy filling the prescription.
Please notify the school immediately, verbally and in writing, if there are any changes to your
childs prescription.
The school may refuse to administer, or allow to be administered, any medication, which,
based on her/his assessment or judgment, has the potential to be harmful, dangerous or
inappropriate. In these cases, the school shall notify the parent/guardian and licensed prescriber and
explain the reason for refusal.
Please take the form on the next page to your childs pediatrician to be completed. Each
medication requires a separate form. Bring the medication authorization form and the medication
to our collection day that will occur the week before the start of school. The collection date and
location will be announced this summer.
If you have any questions, concerns, or need information about medication administration at
school, please feel free to contact the front office and ask to speak to the school nurse.

MEDICATION AUTHORIZATION FORM

Note: Each medication requires a separate form.
Parents complete this section:
Student __________________________________
Birthdate____________________
Grade_________
Parent/ Guardian 1____________________________ Email Adddress__________________________________
Home Phone________________________________ Cell Phone______________________________________
Parent/Guardian 2 ____________________________ Email Address__________________________________
Home Phone_________________________________ Cell Phone_____________________________________
Physician Name ______________________________ Physician Number: _______________________________
I hereby give permission for personnel designated by the principal to give this medication to my child according to the
directions stated. I also authorize school personnel designated in medication administration to contact my childs
practitioner or myself if there is a question regarding medication administration. I agree to notify the school when the
drug is to be discontinued and/or the dosage or time changed. I understand that if the medication is resumed, a new
medication authorization form is required. I understand that any unused medication will be properly disposed of within
10 days if not claimed after discontinuation of the medication.
_________________________________________________________________________________________
(Parent or Guardian Signature)
Date

Physician completes this section for prescription and OTC medication:

Diagnosis/Reason for medication_______________________________________________________________
Medication _____________________________________Dose ______________________________________
Route/Mode of administration_____________________

Frequency__________________________________

Times to be given _____________________ Start date __________________ Stop date __________________

Duration (not to exceed current school year)_______________________________
Special instructions for administration ___________________________________________________________
Potential adverse reactions ____________________________________________________________________
I acknowledge with my signature on this document that I will assist and advise designated school personnel with regard
to the administration of medication described above, which includes accepting direct communication. I further
acknowledge that all instructions should be stated in language of the layperson.
_________________________________________________________________________________________
Practitioner Signature
Date
_________________________________________________________________________________________
Practitioner Name
Phone Number
Please place address stamp here: