AUTHORIZATION FOR STUDENT MEDICATION
To the Principal of _________________________ School
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’s Printed Name
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:
Only asthma inhalers, epinephrine, and
diabetic medications and supplies can
be carried by a student at school.
Do you recommend that any of these be
kept with the student at all times? If so, which?
_____diabetes medication and supplies
Has the student been trained to self-administer the
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’s Printed Name
Signature of Principal
Signature of School Nurse
Signature of staff members assigned to administer the above medications: