Parent/ Guardian Authorization for Prescription Medication Administration

Students Name:___________________________________ Date of Birth___________

Parent/Guardian printed name_____________________________________________

Other Person to be notified in case of medication emergency:

Name: __________________________________ Telephone number: _______________

Name of medication, dose, and frequency: ____________________________________

My son/daughter is currently receiving the following medications (to be completed if not in violation of confidentiality)

___________________________________________________________________________

I consent to have the school nurse or school personnel designated by the school nurse administer the medication prescribed by:

_______________________________ to _____________________________________

Licensed Prescriber                                                             Students Name

I give permission to the School Nurse to share information relevant to the prescribed medication Administration as he/she determines appropriate for my son/daughter’s health and safety.

I understand I may retrieve the medication from the school at any time; however the medication will be destroyed of it is not picked up within one week following termination of the order or one week beyond the close of school.

Parent/Guardian signature______________________________ Date______________

Relationship to Student_________________________________