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
