507.2E2 - 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, the medication dosage, time(s) to administer, and date.
• Authorization is renewed annually and immediately when the parent notifies the school that changes are necessary.

 

                                                                                                                                                             
Prescribed Medication                        Dosage                         Route                           Time at School

 

Special Health Services and instructions, indicated:

                                                                                                                                                

                                                                                                                                               

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

 

                                                                                                /           /          
Prescriber’s Signature                                                   Date

And credentials (when indicated for health service delivery)

 

                                                                                                            /           /          
Parent/Guardian Signature                                                                     Date

                                                                                                                                   
Parent/Guardian Address                                                        Home Phone