Student’s Name (Last, first, middle): ___________________________________________________________
Birthday: _________________________ School: ______________________ Date: _____________________
School medications and special health services are administered following these guidelines:
- 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.
- 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, time(s) to administer, route to administer, and date.
- 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)