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 prescription medication and/or provide special health services listed.  Electronic signatures meet the requirement of written signatures.

●    The prescribed medication is in the original, labeled container as dispensed or the manufacturer's labeled container.

●    The prescription medication label contains the student’s name, name of the medication, the medication dosage, time(s) to administer, route to administer and date.

●    Authorization is renewed annually and immediately as soon as practical when the parent notifies the school that changes are necessary.

 

                                                                                                                                                                    _______________________________   ______________      ____________          _____________         Medication/Health Care                              Dosage                     Route                                Time at School

 

Special Health Services and instructions, as indicated:

___________________________________________________________________________________

 

___________________________________________________________________________________               

                                                                                                                                                    

___________________________

Discontinue/Re-Evaluate/Follow-up Date for Prescribed Medication or Special Health Services listed

 ______________________________________              ___________________________

Prescriber’s Signature                                                       Date

And credentials (when indicated for health service delivery)

                                                                                                                                          

______________________________________               _______________________                                                               

Parent/Guardian Signature                                                   Date

 

______________________________________               ________________________                                                                               Parent/Guardian Address                                                      Phone

Additional Information

 

 

Approved:  3/15/10      
Reviewed:  4/22/15       
Revised:6/24/20; 9/27/23