MEDICATION
A UTHORIZATION
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
Signature____________________________________________________Date________________________
2013