Medication School Authorization Form
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1WJCC Public Schools
Medication Authorization
(Use a separate authorization form for each medication)
Part I
Parent/Guardian Consent
School Year____________________
I hereby request WJCC Public Schools personnel to administer medication as directed by this authorization. I agree to furnish said medication
in the ORIGINAL container supplied by the pharmacy with the label intact. I understand the WJCC Public Schools Medication Administration
Protocol and Policy and accept that the WJCC Public School Board, its employees, agents or designees are not responsible for any effect s of
the medication administration. By signing below, I authorize a representative of the school to share information regarding this medication with
the licensed prescriber.
Student Last Name: ________________________ First Name: _______________________ M.I. _______
Teacher: ______________________________ Grade: ___________ DOB: _______________________
Check Where Appropriate:
I request that the school nurse/designee send appropriate dose(s) of the prescribed medication on field trips to be
given by my child’s teacher or designee.
My child has permission to carry/self-administer inhaled asthma medication. I have provided the school with
appropriate documentation from my child’s health care provider. See Form # H. S. 3-7
My child has permission to carry/self-administer auto-injectable epinephrine. I have provided the school with
appropriate documentation from my child’s health care provider. See Form # H. S. 3-7
_______________________________________ ____________________________ ________________
Parent/Guardian Signature
Daytime Phone
Date
Part II
Prescriber Must Complete and Sign for all Medications
WJCC Public Schools discourage the use of medication by students in school during the school day. Any necessary medication t hat possibly
can be taken before or after school should be so prescribed. School personnel will, when absolutely necessary, administer medication during
the school day and while participating on field trips with parent permission.
Diagnosis: ____________________________________________________________________________
Name of medication: _________________________________Dose: ______________________________
□
Time(s) to be given at school per prescription
:
Daily @ ___________________
(please check each that apply)
□
PRN if morning dose is not given/taken at home and missed dose confirmed by parent
□
PRN for ___________________________________ every _______________________________
□
□
Effective Date:
Current School Year
OR
From _______________ To _______________
Allergies: ___________________________________________________________________________
______________________________________________________________________________________
Prescriber Signature ____________________________ Name
_____________________________
(Print)
Telephone _____________________ Fax _____________________Date __________________________
Williamsburg-James City County Public Schools Health Services 8/2008
Form 3-1
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