__________________________________________ ___/___/___ ___/___/___
Student's Name (Last, First, Middle) Birthday 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, as indicated: __________________________________________________
_____________________________________________________________________________________________
Discontinue/Re-Evaluate/Follow-up Date for Prescribed Medication or Special Health Services Listed: __________________
________________________________________________________________ __________________ Prescriber’s Signature & credentials Date
________________________________________________________________ __________________ Parent/Guardian Signature Date
________________________________________________________________ ___________________ Parent/Guardian address Home Phone
__________________
Business Phone
Additional Information: __________________________________________________________________________________________________
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Approved: 5/13/13 Reviewed: 6/10/19 Revised: 7/14/25