Permission To Administer Medicine Authorization Form - School District Of Clayton
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1SCHOOL DISTRICT OF CLAYTON
PERMISSION TO ADMINISTER MEDICINE
AUTHORIZATION FORM
Parent/Guardian will provide the school with medication in a prescription bottle or original container if
medication is over-the-counter. Will NOT accept any pills in baggies, etc. No medication will be given without
appropriate packaging/dosing instructions.
(PLEASE PRINT)
STUDENT NAME____________________________________ GRADE/TEACHER__________________________
NAME OF MEDICATION_______________________________________________________________________
REASON FOR MEDICATION____________________________________________________________________
PRESCRIPTION__________
OTC__________
DOSE__________
TIMES GIVEN__________
FORM OF MEDICATION
_____TABLET/CAPSULE
_____INHALER
_____LIQUID
_____NEBULIZER
_____INJECTION
PHYSICIAN’S NAME_________________________________________________PHONE #__________________
I request and authorize school personnel to give this medication to this student and to contact the physician directly if there are any
concerns about the medication or the student’s condition. I understand that I have the ultimate responsibility for providing the
school with an adequate supply of medication and to inform the school immediately if any information provided on this form
changes OR if the administration of the medicine should stop. The school nurse will not be held liable for any effects as a result of
giving the medication.
PLEASE PRINT: PARENT/GUARDIAN NAME______________________________________________________________________
PARENT/GUARDIAN SIGNATURE______________________________________________DATE_____________________________
DAY-TIME NUMBER_________________________________EMAIL___________________________________________________
Metered-dose inhalers for students with asthma may be carried by students provided a licensed professional’s
order is received and the parent/guardian has signed a District waiver.
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IF YOU ARE PROVIDING AN OTC MEDICATION THE FOLLOWING AUTHORIZATION MUST BE COMPLETED BY A
PROFESSIONAL LICENSED TO PRESCRIBE.
NAME OF PATIENT___________________________________________________________________________
CONDITION BEING TREATED___________________________________________________________________
MEDICATION_______________________________________________________________________________
DOSAGE + TIMES_______________________________________ DURATION___________________________
POSSIBLE SIDE EFFECTS AND/OR COMMENTS_____________________________________________________
__________________________________________________________________________________________
PHYSICIAN’S NAME/PLEASE PRINT______________________________________________________________
PHYSICIAN SIGNATURE___________________________________ DATE_______________________________
02/20/13
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