__________________________________________ ___/___/___ ___/___/___
Student's Name (Last, First, Middle) Birthday Date
School medications and special health services are administered following these guidelines:
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Parent has provided a signed, dated authorization to administer prescription medication and/or provide special health services listed
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Electronic signatures meet the requirement of written signatures.
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The prescribed medication is in the original, labeled container as dispensed.
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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.
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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