507.02E2 PARENTAL AUTHORIZATION AND RELEASE FORM FOR THE ADMINISTRATION OF PRESCRIPTION DRUGS TO STUDENTS

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

Student's Name (Last), (First),  (Middle)                Birthday                    School                    Date

 

School medications and special health services are administered following these guidelines:

 

• Parent has provided a signed, dated authorization to administer 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.
• The prescription medication label contains the student’s name, name of the medication, the medication dosage, times(s) to administer, route to administer, and date.
• Authorization is renewed annually and as soon as practical when the parent notifies the school that changes are necessary.

 

                                                                                                                                                             

Prescribed Medication                         Dosage                         Route                           Time at School

 

                                                                                                                                               

 

                                                                                                                                               

Special Health Services and instructions, if 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's Signature                                                                     Date

 

                                                                                                                                   

Parent's Address                                                                        Home Phone

 

                                                                                                                                   

Additional Information                                                             Business Phone