Authorization For Administering Prescription Medication Form
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AUTHORIZATION FOR ADMINISTERING PRESCRIPTION MEDICATION
*USE A SEPERATE AUTHORIZATION FORM FOR EACH MEDICATION*
Student's Name
PARENTAL CONSENT
I am the parent or legal guardian of
. I give my permission
for him/her to take the following prescribed medication while attending the Virginia Governor's School for
Agriculture. I hereby release the Virginia Governor's School for Agriculture and its agents and employees
from any claims or liability connected with its reliance on this permission and agree to indemnify, defend,
and hold them harmless of any claim or liability connected with such reliance. I authorize a representative
of the school to share information regarding this medication with the licensed prescriber.
Parent/Legal Guardian Signature
Daytime Phone
Date
**************************************************************************************
MEDICATION AUTHORIZATION
(This section to be completed by Licensed Prescriber only! Please print or type
)
.
Relevant Diagnosis (please describe any problems associated
_________________________________________________________________
Medication:
Dates medication must be administered at school:
___Short Term ____________ - _________
___ Every Day
___ Episodic/Emergency Events ONLY
Dosage (Amount): _______________Route: ____________Form: ________Time(s) of day: ________
A.Can serious reactions occur if the medication is not given at the time prescribed, or if a dose or dosages are missed?
If YES, please describe:
BDo serious reactions/adverse side effects from this medication occur? If YES, please describe:
C.Action treatment for reactions: __________________________________________________
(Drug information sheet may be attached)
Special handling instruction: ___ Refrigeration
___ Keep out of sunlight
___ Other: _______________________
This student is both capable and responsible for self-administering this medication:
___ No
___ Yes-supervised
___ Yes-unsupervised
The Governor's School assumes students are medically stable and able to self-administer all prescribed medications. If
there are any contradications or disabilities that would preclude this student from self-administration of medication,
please explain on the reverse of this form.
_______________________________________________________________________________________________________
Licensed prescriber's name: ____________________ __________ Telephone number: ____________________________
Emergency number: _____________________________________________
Prescriber's Signature: ___________________________________________________ Date: ____________________
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