School Medication Authorization Form; Self-Administration Of Emergency Medications Template

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THIS SIDE TO BE COMPLETED IF MEDICATIONS FROM HOME ARE TO
BE GIVEN AT SCHOOL (Rx and OTC)
Centralia High School District 200
School Medication Authorization Form
Name of Student__________________________Date of Birth____________Grade_____
Name of
Parent__________________________________________________________________
Address_________________________________________Phone #_________________
Physician’s Name_________________________________Phone #__________________
Physician’s
Address_________________________________________________________________
Name of Medication__________________________Dosage of Medication___________
Directions for Use_________________________________________________________
Reason for Medication (Indicate type of illness)_________________________________
Other Medication(s) student is receiving at
home__________________________________________________________________________
__________________________________________________________________________
Possible Side Effects of Medication(s)_________________________________________
The approximate length of time that the student will receive this medication
is:______________________________________________________________________
X________________________________________________Date_________________
Parent Signature
X________________________________________________Date__________________
Physician Signature
Note to Physician and Parent: If medication is an inhaler or an EpiPen®, and it is medically
necessary for the student to carry the inhaler or EpiPen® with him/her at all times during school
hours, please complete and sign the Self Administration of Emergency Medications form on the
reverse side.
Please complete the reverse side if the student will need to carry an inhaler of EpiPen while at school.

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