507.2E2 Parental Authorization and Release Form for the Administration of Medication to Student

Code No. 507.2E2

PARENTAL AUTHORIZATION AND RELEASE FORM FOR THE ADMINISTRATION
OF MEDICATION OR SPECIAL HEALTH SERVICES TO STUDENTS

____________________________________ ___/___/___ _____________________ ___/___/___
Student's Name (Last), (First), (Middle) Birthday School Date

School medications and special 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, route to administer, 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, in 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)

Parent/Guardian Signature _______________________________________ Date ___________________

_________________________________________________ __________________
Parent/Guardian Address Home Phone

Additional Information Business Phone

______________________________________________________________________________________________________________________

Authorization Form

Approved: 7/15/2019 Reviewed: Revised: 08/14/2023