504.31-E1 - Parent/Guardian Authorization and Release Form for the Administration of Medication or Special Health Services to Students

CLICK HERE TO DOWNLOAD THE PARENT/GUARDIAN AUTHORIZATION AND RELEASE FORM FOR THE ADMINISTRATION OF MEDICATION OR SPECIAL HEALTH SERVICESTO STUDENTS

Student’s Name (Last, first, middle): ___________________________________________________________

Birthday: _________________________ School: ______________________ Date: _____________________

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

  1. Parent/guardian 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.
  2. The prescribed medication is in the original, labeled container as dispensed.
  3. The prescription medication label contains the student’s name, name of the medication, the medication dosage, time(s) to administer, route to administer, and date.
  4. Authorization is renewed annually and as soon as practical when the parent/guardian 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: _____________

Prescriber’s Credentials (when indicated for health service delivery): _______________________________

Parent/Guardian Signature: ___________________________________________ Date: __________________

Parent/Guardian Address: ________________________________________ Phone: ____________________

Additional Information: ___________________________________________________________________

Reviewed: 7/13; 12/20
Revised: 10/14; 4/16; 10/17; 6/20; 8/21; 8/23
Related Policy: 504.31; 504.31-E2; 504.32
IASB Reference: 504.07-E(2)