_________________________________ ___/___/___ _________________ ___/___/___
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
