Authorization For Student Medication printable pdf download

AUTHORIZATION FOR STUDENT MEDICATION

To the Principal of _________________________ School

Date___________________

I, the parent/guardian of ______________________, whose birth date is________________, request the

following medication be given to my child during school hours. I release school personnel from any liability

involved with administering this medication according to the doctor’s instructions below. I understand that this

form is valid only with a licensed medical provider’s signature. I authorize the school nurse and the medical

provider to communicate as needed to ensure the safe administration of the medication. I UNDERSTAND

THAT THIS AUTHORIZATION IS IN EFFECT FOR ONE YEAR AND A NEW FORM MUST BE

SIGNED BY A MEDICAL PROVIDER EACH SCHOOL YEAR.

_______________________________

___________________________

____________

Parent Signature

Parent’s Printed Name

Date

In accordance with the request of the parent above I request that the following medication be given to

___________________ by school personnel during regular school hours:

Diagnosis

Medication

Dosage

Time

1. ______________________

___________________

______

__________

2. ______________________

___________________

______

__________

3. ______________________

___________________

______

__________

Only asthma inhalers, epinephrine, and

diabetic medications and supplies can

be carried by a student at school.

_____asthma inhaler

Do you recommend that any of these be

_____epinephrine

kept with the student at all times? If so, which?

_____diabetes medication and supplies

Has the student been trained to self-administer the

Yes

medication and are they capable of doing this safely?

Potential side effects of these medications

the school staff needs to be aware of:

________________________________________________

_________________________________________________

Additional instructions to the school:

_________________________________________________

Note: If a request is being made to administer Glucagon to a diabetic student in an emergency low- blood sugar

situation, an additional, specific form, the Utah State Administration of Glucagon form, must be signed by the

parent and physician and kept on file at the school.

__________________________

______________________

_____________

Physician Signature

Physician’s Printed Name

Date

____________________ _________

______________________

_____________

Signature of Principal

Date

Signature of School Nurse

Date

Signature of staff members assigned to administer the above medications:

1.___________________________

2._________________________

Date ________________

Authorization For Student Medication

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