Medication Administration/medical Authorization And Release Form


Muscogee County School District
Department of Health Services
Medication Administration/Medical Authorization and Release
This form must be completed by the parent/guardian and returned to the school principal in order for the
Muscogee County School District to assist parents when their child requires medication during school hours.
The medication will only be administered if it is delivered to the principal or designated staff member by the
parent or guardian. Prescription medication must remain in the original prescription container and be properly
labeled with the child’s name and specific instructions regarding dosage and time of administration.
Student______________________________________ Age___ Grade___
Teacher’s Name _________________________ School______________________________________
Address of Student______________________________ Home number_________________________
Name of Father/Guardian_______________________________ Wk number______________________
Name of Mother/Guardian______________________________ Wk Number______________________
Name of person to contact in an emergency if neither parent/guardian is available__________________
___________________________________ Relationship to Student_____________________________
Home Number___________________ Cell Number_________________ WK Number_______________
Name of medication to be given__________________________________________________________
Dosage (amount) and specific time(s) medication to be given___________________________________
Any know allergies to food or drugs? Yes___ No___ If yes, please list__________________________
Name and address of prescribing physician_________________________________________________
Any known or expected side effects from this medication______________________________________
Please list other medications that the student presently taking__________________________________
Special Instruction____________________________________________________________________
The undersigned hereby releases and agrees to hold harmless and indemnify the Muscogee County School District and
any employee of this school district from any liability whatsoever resulting from administration or nonadministration of the
above described medication to our child during school hours in accordance with the above instructions. I will notify the
clinic worker, school nurse or school if this medication is changed or discontinued. My signature below indicates that I
have read this statement and agree to the terms set forth.
I give my permission for the school nurse to contact my child’s physician Yes___ No___
Signature of Parent/Guardian_______________________________________________ Date_______________
Signature of Principal_____________________________________________________
Signature of School Nurse_________________________________________________
Revised 4/2011 


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