_________________________________ ___/___/___ _________________ ___/___/___
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)
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Parent/Guardian Signature Date
Parent/Guardian Address Home Phone
