507.02E2 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 health services are administered following these guidelines:

• Parent has provided a signed, dated authorization to administer prescribed medication and/or provide the special health services listed.  Electronic signatures meet the requirement of written signatures.

• The prescribed medication is in the original, labeled container as dispensed or the manufacturer's labeled container.

• The prescribed 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.

                                                                                                                                                            

Medication/Health Care                      Dosage                        Route                          Time at School

                                                                                                                                              

                                                                                                                                              

Special Health Services and Instructions, as indicated:

                                                                                                                                              

                                                                                                                                              

Special Directives, Signs to Observe and Side Effects

           /           /           

Discontinue/Re-Evaluate/Follow-up Date

                                                                                               /           /           

Prescriber’s Signature                                                   Date

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                                                                                                           /           /           

Parent's Signature                                                                    Date 

                                                                                                                                   

Parent's Address                                                                        Phone

                                                                                                                                   

 Additional Information                                                             Business Phone

                                                                                                                                               

                                                                                                                                             

                                                                                                                                              

 

Approved 9/23/11     Reviewed  8/18/2021              Revised   8-16-23