School Medication Authorization Form Page 2
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2FOR STUDENT SELF-ADMINISTERING EPINEPHRINE OR DIABETES MEDICATION ONLY
TO BE COMPLETED BY THE STUDENT’S LICENSED PRESCRIBER and cosigned by the student’s
parent/guardian
Student Name______________________________________________________Grade/Teacher____________
Diagnosis ______________________________ Name of Medication__________________________________
Dosage: _______________________________ Route _____________________________________________
Time/Circumstances when medication should be administered________________________________________
Possible side effects__________________________________________________________________________
Date of Rx___________________________________ Discontinuation date_____________________________
Self-Administration of Epinephrine: The student listed above has a life threatening allergy that medically necessitates the
immediate administration of epinephrine followed by emergency medical attention. I have determined that it is medically
necessary for this child to carry an epinephrine auto-injector. The student has been instructed in the self-administration of the
medication listed above and is capable of administering the medication independently. The student understands the need for
the medication and the necessity to notify a staff member and the health office immediately following the self-administration
of the epinephrine auto-injector.
Self-Administration of Diabetes Medication: The student listed above has been diagnosed with diabetes.
I have
determined that it is medically necessary for this child to possess his/her diabetes medication and the equipment and supplies
necessary to monitor and treat his/her diabetic condition pursuant to his/her Diabetes Care Plan. The student has been
instructed in the self-administration of the medication listed above and use of his/her diabetes supplies and equipment and is
capable of doing this independently. The student understands the need for the medication and the necessity of reporting to
school personnel any unusual side effects.
_______________________________________________ __________________________________________________
Physician’s Name (Print)
Signature of Physician
phone #
Date
_________________________________________________________________________________________________
Parent/Guardian Signature
Date
ASTHMA
PERMISSION FOR STUDENT TO SELF-ADMINISTER
MEDICATION ONLY
TO BE COMPLETED BY THE STUDENT’S PARENT/GUARDIAN
Student Name___________________________________________________Grade/Teacher________________
Name of Medication ____________________________________________ Dosage _____________________
Time/Circumstances when medication should be administered________________________________________
Possible side effects__________________________________________________________________________
Date of Rx______________________________________ Discontinuation date_________________________
Self-Administration of Asthma Medication: My child has been diagnosed with asthma and has been prescribed asthma
medication by a qualified health care professional. I hereby authorize my child to carry his/her asthma medication and to
self-administer his/her medication as prescribed by his/her physician. My child’s physician has instructed my child in the
self-administration of his/her medication and has indicated that my child is capable of doing this independently. My child
understands the need for the medication and the necessity of reporting to school personnel any unusual side effects. When
able to, I will provide the school with an extra supply of his/her medication with a prescription label for use in the event that
he/she forgets to bring his/her asthma medication to school on a particular day.
Parent/Guardian Signature: _________________________________________________ Date: ______________
1/2012
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