Medication Administration/medical Authorization And Release Form printable pdf download

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____________________________________________________________________

STATEMENT OF PARENT OR GUARDIAN

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_____________________________________________________

Date_______________

Signature of School Nurse_________________________________________________

Date_______________

Revised 4/2011

Medication Administration/medical Authorization And Release Form