KENOSHA UNIFIED SCHOOL DISTRICT NO. 1
MEDICATION AUTHORIZATION FORM
SCHOOL NAME: _________________________________ PHONE: _____________ FAX: _____________
ONE MEDICATION PER FORM
Health Care Provider to complete. Health Care Provider signature required.
Parent/Guardian signature required.
Parent/Guardian to complete. Parent/Guardian signature required.
Medication to be administered as directed.
Student Name: _____________________________________________________ DOB: ____/____/________
Time(s) Administered: ______________________________________________________________________
Reason for Medication: _____________________________________________________________________
Student may carry medication for Emergency purposes:
Additional directions/symptoms: ______________________________________________________________
Health Care Provider Signature: _______________________________________ Date: ____/____/________
Health Care Provider Name (Please Print): ______________________________________________________
Address: __________________________________________ Phone: _____________ Fax: _____________
NOTE: Parent/Guardian signature permits designated school staff to dispense medication to the above student
and to contact the health care provider at any time with questions or concerns related to this student’s medical
condition and medication.
Parent/Guardian Signature: ___________________________________________ Date: ____/____/________
Parent/Guardian Name (Please Print): _________________________________________________________
Daytime Phone Number: ____________________________________________________________________
CRITERIA FOR DISPENSING MEDICATION
1. Authorization: Students requiring medication at school, including herbal and vitamin supplements, shall
provide a completed “Medication Authorization Form”. Prescription medications require a signature from
both a health care provider and parent/guardian. Non-prescription medications require the
parent/guardian signature. The parents must notify the school when the drug is discontinued or for any
changes. An updated medication authorization form is required for all changes in medication, dosage, or
administration time. All medication authorization forms must be renewed annually. All unclaimed
medication at the end of the school year will be disposed of per policy.
2. Container: All medication must be supplied in the original container. Prescription medications require the
pharmacy label. Non-prescription medication must be in the original container with the directions on the
container including student name. All medication shall be kept in a locked cabinet.
3. Delivery to School: It is the responsibility of the parent/guardian to provide and deliver to the school all
authorized medication and replace expired medication.
Hedata\Clerical\Nursing\forms\kusd med authorization form 2011