Authorization for Administration of Medication at School
Name of Student:
Birthdate:
School:
School Year:
Phone Number: (
Medical Condition
1
)
Medication
Strength
/
Grade:
Fax Number: (
ICD 10
Code
/
Dose
)
Time
Route
Possible Side
Effects
2
3
4
Other Considerations/Directions:
Start Date:
Stop Date:
(All authorizations expire at the end of the school year.)
Print or Type Name of Physician/Licensed Prescriber
Physician’s/Licensed Prescriber’s Signature
Clinic Address
(
)
Phone Number
(
)
Fax Number
Date
1.
2.
3.
4.
5.
6.
Date
Parent/Guardian Authorization
I request that the above medication(s) be given during school hours as ordered by this student’s physician/licensed prescriber. I
also request the medication(s) be given on field trips, as prescribed.
I release school personnel from liability in the event adverse reactions result from taking the medication(s).
I will notify the school of any change in the medication(s), (ex: dosage change, medication is discontinued, etc.)
I give permission for the school nurse to communicate with the student’s teachers about the action and side effects of this
medication(s).
I give permission for the school nurse to consult with the above named student’s physician/licensed prescriber regarding any
questions that arise with regard to the listed medication(s) or medical condition(s) being treated by the medication(s).
I give permission for the medication(s) to be given by designated personnel as delegated by the school nurse.
Parent/Guardian Signature
Relationship to Student
NOTE: Medication is to be supplied in the original/prescription bottle/container.
LSN 6.2015