507.2E2 Parental Authorization and Release Form for the Administration of Prescription Drugs to Students

Code No. 5O7.2E2

PARENTAL AUTHORIZATION AND RELEASE FORM FOR THE ADMINISTRATION OF PRESCRIPTION MEDICATION TO STUDENTS

__________________________    __/___/___  _______________  __/__/__

Student’s Name (Last/First/M)          Birthday       School                     Date

School medications and health services are administered following these guidelines:      

• Parent has provided a signed, dated authorization to administer medication and/or provide the health service.
• The medication is in the original, labeled container as dispensed or the manufacturer’s labeled container.
• The medication label contains the student’s name, name of the medication, directions for use, and date.
• Authorization is renewed annually and immediately when the parent notifies the school that changes are necessary.

 ______________________    _____________    ____________   ________________

Medication/Health Care               Dosage                  Route                 Time at School

___________________________________________________________________________

___________________________________________________________________________

Administration instructions

___________________________________________________________________________

___________________________________________________________________________

Special Directives, Signs to Observe and Side Effects

_______________________________________

Discontinue/Re-Evaluate/Follow-up Date

________________________________      _____________________

Prescriber’s Signature                                      Date

________________________________      ______________________

Prescriber’s Address                                        Emergency Phone

I request the above named student carry medication at school and school activities, according to the prescription, instructions, and a written record kept. Special considerations are noted above.  The information is confidential except as provided to the Family Education Rights and Privacy Act (FERPA). I agree to coordinate and work with school personnel and prescriber when questions arise.  I agree to provide safe delivery of medication and equipment to and from school and to pick up remaining medication and equipment.

 

__________________________________________            ________________

Parent’s Signature                                                                   Date

__________________________________________            ______________________

Parent’s Address                                                                      Home Phone

_________________________________________                ____________________

Additional Information                                                                Business Phone

____________________________________________________________________

______________________________________________________________________

_____________________________________________________________________

Authorization Form

Reviewed 8-16-2021