Medication Authorization Form

Medication Authorization Form

Any student who is required to take, during the regular school day, medication prescribed for him by a physician, may be assisted by designated school personnel when the school has received a written authorization from a physician and from the parent or guardian. No other medication will be administered or provided by school personnel. This includes all non-prescription medication.
Student's Name*
Date of birth *
Physician name and phone number*
Allergies to medication*
Medication Name, as it appears on the label*
Dosage to be administered *
Time of day and frequency of administration*
Reason for medication*
Terms and Conditions

NO MEDICATION WILL BE GIVEN IF NOT IN ITS ORIGINAL, PROPERLY LABELED CONTAINER. All medication must be delivered to the dean of students' office by a parent and picked up from the dean's office by a parent at the end of the year.
THIS PORTION TO BE COMPLETED BY PARENT/GUARDIAN

I am the parent/guardian of the above student and have lawful custody of said child. I hereby give consent to designated school personnel to administer medication and/or treatment as specified by his health provider. Furthermore, I hereby give consent to the school to receive from or send to the health care provider any information concerning my child’s medical condition. In the event that the school grants my child permission to carry and self-administer medication(s), a separate, contractual agreement of responsibilities must be signed by student, parent, physician, and school official.
Agreement to terms and conditions*

I agree to the terms and conditions above
Signature*

Clear
Date that consent given *
Parent Email*
example@example.com