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

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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)