508.3E2 - 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 medication and/or provide the health service.
• The medication is in the original, labeled container as dispensed or the manufacturer’s labeled container.
• The medication label contains the student’s name, name of the medication, directions for use, and date.
• Authorization is renewed annually and immediately when the parent notifies the school that changes are necessary.

_____                                                                                                                                                             
Medication/Health Care                      Dosage                                    Route                    Time at School

                                                                                                                                               

                                                                                                                                               

Administration instructions

                                                                                                                                               

                                                                                                                                               

Special Directives, Signs to Observe and Side Effects

            /           /          
Discontinue/Re-Evaluate/Follow-up Date

                                                                                                /           /          
Prescriber’s Signature                                                 Date

                                                                                                                                   
Prescriber’s Address                                                  Emergency Phone

I request the above named student carry medication at school and school activities, according to the prescription, instructions, and a written record kept. Special considerations are noted above. The information is confidential except as provided to the Family Education Rights and Privacy Act (FERPA).  I agree to coordinate and work with school personnel and prescriber when questions arise. I agree to provide safe delivery of medication and equipment to and from school and to pick up remaining medication and equipment.

                                                                                                            /           /          
Parent’s Signature                                                                   Date

                                                                                                                                   
Parent’s Address                                                                    Home Phone

                                                                                                                                   
Additional Information                                                             Business Phone

                                                                                                                                               

                                                                                                                                               

                                                                                                                                               

Authorization Form