507.2E2 - Parental Authorization and Release Form for the Administration of Prescription Medication 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 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 as soon as practical when the parent 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

                                                                                                                                                     /           /          
Prescriber’s Signature and credentials(when indicated for health services delivery)                  Date

                                                                                                            /           /          
Parent/Guardian Signature                                                                     Date

                                                                                                                                   
Parent's Address                                                                       Home Phone

                                                                                                                                   
Additional Information                                                             Business Phone

Authorization Form

Adopted: 6/18/18
Reviewed: 04/22/2024
Revised:  8/15/2023