Medication Authorization Form

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No   m edications   ( non-­‐prescription/over   t he   c ounter   o r   p rescription)   w ill   b e   a dministered   b y   t he   s chool   n urse,   o ther   s chool   p ersonnel  
or   s elf   ( student)   w ithout   t he   w ritten   a uthorization   o f   a   p hysician   a nd   p arent.      
Student’s   N ame____________________________________________________________________Grade____________________    
Drug   A llergies_______________________________________________________________________________________________  
Date   o f   B irth_______________________________________Height____________________Weight_________________________
I,   _ _____________________________(do___)   ( do   n ot___)authorize   m y   c hild’s   h ealth   c are   p rovider   a nd   t he   s chool   n urse  
to   d iscuss   m y   c hild’s   h ealth   c oncerns   a nd/or   e xchange   i nformation   p ertaining   t o   s chool   h ealth   f orms.     T his   a uthorization  
will   b e   i n   p lace   u ntil   o r   u nless   y ou   w ithdraw   i t.     Y ou   m ay   w ithdraw   y our   a uthorization   a t   a ny   t ime   b y   c ontacting   y our  
child’s   s chool.     I   a uthorize   t he   m edication(s)   c hecked   b elow   b y   t he   c are   p rovider   t o   b e   g iven   a s   o rdered   t o   m y   c hild.  
Signature   o f   p arent/legal   g uardian__________________________________Date_______________  
  The   o ver   t he   c ounter   m edication   d osage   w ill   b e   a dministered   a ccording   t o   t he   m anufacturer’s     r ecommendations   o n   t he  
label   u nless   o therwise   i ndicated   b y   a   p hysician.     G eneric   s ubstitutions   m ay   b e   u sed   f or   n on-­‐prescription   m edications  
listed.     T his   f orm   w ill   a lso   b e   t he   a uthorized   f orm   u sed   f or   o ff   c ampus   a ctivities,   i ncluding   o vernight   t rips.  
Non-­‐prescription   m edication   s tocked   i n   o ffice   i nclude   t he   f ollowing   ( please   c heck   t hose   t hat   a re   t o   b e   g iven   a s   n eeded):              
¨   T ylenol   ( Acetaminophen)                               ¨   M otrin   ( Ibuprofen)                               ¨   B enadryl                                        
¨   C ough   d rops                                                                             ¨   T ums  
¨   N eosporin/Hydrocortisone   l otion/Benadryl   s pray   a nd   l otion/topical   s ting   r elief  
Please   l ist   a ny   o ther   m edication   w hich   w ould   n eed   a dministering   d uring   s chool   o r   s chool   r elated   a ctivities,  
whether   t o   b e   a dministered   b y   s chool   p ersonnel   o r   s elf   ( student).  
Name   o f   m edication______________________________________Dosage____________________________  
Route__________________________________Hours   t o   b e   g iven___________________________________  
Student   m ay   c arry   a nd   s elf   a dminister   t he   m edication   o rdered:       y es_____       n o_____  
Physician/Nurse   P ractitioner/PA        


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Parent category: Business