Authorization for Medication Administration By School Personnel
Student Name *
School Grade 2020-21 *
Today's Date *
MM
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DD
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YYYY
Parent/Guardian Name completing this form *
Parent/Guardian email address *
Medication Type *
Medication Name *
Dose (how much?...please indicate mg amount) *
Frequency (how often) *
The above information is required to be also noted on the Pharmacy Label for all prescription medications.
Time (is there a specific time your child needs this medication) - leave blank if no
Time
:
Duration (start date for this medication protocol) *
MM
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DD
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YYYY
Duration (end date for this medication protocol) *
MM
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DD
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YYYY
Reason for the medication *
Special Instruction or other pertinent information
I understand I am responsible to provide this medication and maintain the supply as needed. I understand I am to notify the school in writing of any changes. I understand I am required to pick up all unused medication by the last day of school as unused medication will be discarded. Parent or Guardian Signature: By typing your name in the signature box and clicking submit at the end of this document, you agree that you are electronically signing this agreement in accordance with the Electronic Signatures Act (Public Law No: 106-229), and agree to be bound by all terms and conditions. (type name) *
Date *
MM
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DD
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YYYY
This authorization applies only to the student and medication listed above and for the duration of the treatment noted. This document also authorizes an exchange of information, as necessary, between appropriate school personnel, and/or my child's health provider.
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