507.2E2 - Parental Authorization and Release Form for the Administration of Prescription Medication to Students

PARENTAL AUTHORIZATION AND RELEASE FORM FOR THE ADMINISTRATION OF MEDICATION OR SPECIAL HEALTH SERVICES 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  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. 
• The prescription medication label contains the student’s name, name of the medication, medication dosage, time(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, in indicated:

                                                                                                                                               

                                                                                                                                               

                                                                                                                                               

                                                                                                                                               

            /           /          
Discontinue/Re-Evaluate/Follow-up Date for Prescribed Medication or Special Health Services Listed

                                                                                                                                                                                                    /           /           

Prescriber’s Signature  And credentials (when indicated for health service delivery)                                         Date

I request the above-named student carry medication at school and school district activities, according to the prescription or other medication administration instructions, and a written record kept. Special considerations are noted above. The information is confidential except as provided by the Family Education Rights and Privacy Act (FERPA) and any other applicable law.  I agree to coordinate and work with school district 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.  Procedures for medication disposal shall be in accordance with federal and state law.

 

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Parent/Guardian Signature                                                            Date

                                                                                                                                   
Parent/Guardian Address                                                              Home Phone

                                                                                                                                   
Additional Information                                                  Business Phone

                                                                                                                                               

                                                                                                                                               

                                                                                                                                               
Authorization Form