_________________________________ ___/___/___ _________________ ___/___/___
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
