_________________________________ ___/___/___ _________________ ___/___/___
Student's Name (Last), (First), (Middle) Birthday School Date
School medications and health services are administered following these guidelines:
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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.
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The prescribed medication is in the original, labeled container as dispensed or the manufacturer's labeled container.
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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.
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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
