Medication Authorization Form - A Parent/guardian Authorization Form printable pdf download

HILLIARD CITY SCHOOL DISTRICT

MEDICATION AUTHORIZATION FORM - A

PARENT/GUARDIAN AUTHORIZATION

PURPOSE: Completion of this form is necessary to comply with the Ohio Revised Code 3313.713

and Hilliard Board of Education policy.

Student Name: _____________________ Address: ______________________ DOB: _______

School: __________________________ Teacher: ______________________ GRADE: _____

PART I.

TO THE PARENT/GUARDIAN: Students needing medication are encouraged

to receive the medication at home whenever possible. The following information

is necessary for any student who consumes medication in school. Over the counter

medication must be accompanied by both licensed prescriber and parent authorization for

students in grades K - 6. By signing this form, the parent/guardian agrees to the

following:

1. I am requesting permission for the student named above to receive and consume medication as

specified on the physician authorization form.

2. I assume full responsibility for safe delivery of medication to the appropriate school personnel.

3. I assume full responsibility for record keeping of the amount of medication at school and for

replenishing the medication when needed.

4. I authorize Hilliard City Schools personnel to communicate with my health care provider as

necessary concerning the use of this medication.

5. I will deliver medication only in its original or pharmaceutical container that is labeled by the

pharmacy with the proper name and dosage.

6. I will notify the school immediately if there is any change in the use of medication.

7. I understand that it is my child's responsibility to come to the office to receive the medication.

8. I understand that no person who is authorized by the Board of Education to administer medication

will be liable for administering or failing to administer the medication unless such person acts in a

manner constituting negligence or wanton or reckless misconduct.

9. I understand that all medication remaining at school after the last day of school will be discarded.

10. I am responsible for knowing the information with regard to medication administration in my

child's student handbook.

Name of medication _______________________ Dosage___________ Frequency____________

Signature of Parent/Guardian: ____________________________________ Date: ____________

Home phone: _______________ Work phone: ________________ Pager/Cellular: ____________

PART II: Pertains ONLY to Inhalers and Epinephrine Auto-Injectors

My child has permission to carry and self- administer this medication. NOTE: An authorization form

signed by the licensed prescriber must accompany all inhaler and Epinephrine requests for

grades K - 12. State law requires the parent/guardian to supply the school with a back-up

auto-injector, in addition to the injector being carried by the student.

Signature of Parent/Guardian: __________________________________ Date: ____________

PART III: Grades 7-12 ONLY: Non-prescription medication (over the counter) authorization

Name of medication __________________Dosage __________ Frequency_____________

Note: The student may only carry a one-day supply of medication on his/her person. No such

medication shall be given to another student. School personnel will not be responsible for

administration or supervision of self- administered medication.

Signature of Parent/Guardian: ____________________________________ Date: ____________

Revised 3/09

Medication Authorization Form - A Parent/guardian Authorization Form

Related Articles

Related forms

Related Categories