AUTHORIZATION OF STUDENT MEDICATION

To the Principal of Date:

I, the parent/guardian of: DOB:

would like to request that medication be given to my child at school according to the directions specified
below by my family doctor. I also release any and/or all school personnel from any liability that could be
brought about by administering this medication as requested here by my child’s physician. I understand
this form is valid only with the physician’s signature. I also authorize the nurse and the physician to
communicate sufficiently to ensure safe administration of the medication in the school setting.

Parent/Guardian Name (please print) Parent/Guardian Signature

In accordance with the request of the parent whose name is listed above, I request the following medication(s)
be given to the above named student by school personnel at school, during regular school hours.

Diagnosis Medication to be given Dosage (mg) Time to be Given

1
2
3
Yes No Would this medication be dangerous if taken by any person other than the one for whom
it was prescribed?

Yes No Should this medication be kept in a locked container?

Yes No Does this medication require storage under refrigeration?

Yes No Would this medication prevent the child from participation in field trips or other school
activities?

Yes No Is any of this medication specifically for seizure control?

Yes No Do you recommend that this medication be kept on his person at all times? (i.e. asthma
inhaler and/or epi-pen for severe allergy or other severe allergic condition).

Any specific instructions to the school:

Physician’s Name (please print) Physician’s Signature Phone

Principal Date School Nurse Date

School person to give medication Date trained by School Nurse

Alternate person to give medication Date trained by School Nurse

THIS AUTHORIZATION IS IN EFFECT FOR ONE YEAR.

A NEW FORM MUST BE SIGNED BY THE DOCTOR EACH YEAR.