Guardian Authorization For Medication Administration At School (Page 2 of 2) in pdf

Guardian Authorization For Medication Administration At School Page 2

Pasco County Schools

Parent/Guardian Authorization for Medication Administration at School

I have read Pasco County Schools’ General Guidelines for Administration of Medication at School and

permission is hereby granted to

Pasco County Schools’

(Name of school)

trained personnel to administer the following medication to:

(Student’s name)

(Student #)

(Grade)

(DOB)

for the treatment of

(Health condition)

Name of prescribing Health Care Provider:

Known Allergies:

Name of medication:

Dose of medication:

Route of medication:

Time to be given at school:

Special instructions (including reasons for which medication must be administered during the school day or

at after school activities):

Possible reactions / side effects:

I hereby authorize designated Pasco County Schools’ staff to reciprocally release verbal, written, faxed, or

electronic student health information regarding the above named child for the purpose of giving necessary

medication or treatment while at school. I understand Pasco County Schools protects and secures the privacy

of student health information as required by federal and state law and in all forms of records, including, but

not limited to, those that are oral, written, faxed or electronic. I hereby authorize and direct that my child’s

medication or treatment be administered in the manner set forth in this authorization form. I understand that I

am responsible to furnish/restock all supplies and medications and that any unused medication that is not

retrieved by me at the end of the school year will be destroyed.

Date: _____________________

(Signature of Parent / Guardian)

Note: Give parent copy of General Guidelines for Administration of Medication at School

Rev. 7/2015

Guardian Authorization For Medication Administration At School Page 2