Authorization Of Medication For A Student At School Form
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1GUILFORD COUNTY SCHOOLS
AUTHORIZATION OF MEDICATION FOR A STUDENT AT SCHOOL
Check one:
_____ Prescription
_____ Non-Prescription
School: _________________________________ School Address:__________________________________
Name of Student: ____________________________________ Date of Birth:_____________________________
IN ORDER TO KEEP THIS STUDENT IN OPTIMUM HEALTH AND TO HELP MAINTAIN MAXIMUM SCHOOL
PERFORMANCE, IT IS NECESSARY THAT MEDICATION BE GIVEN DURING SCHOOL HOURS.
Prescribing Health Care Clinician: __________________________________Phone: ______________________
Medication: _____________________________ Diagnosis: _________________________________________
Dosage and Frequency (amount to be given and time):__________________________________________________
Expected Dates for Administration: ______________________________________________________________
Possible Adverse Reactions That Should Be Reported to Health Care Clinician: ___________________________
___________________________________________________________________________________________
Check here if serious reaction can occur if
Check here if serious reaction can occur
medication not given exactly as prescribed.
even when medication is administered
properly.
Student has been instructed, understands and has demonstrated the skill to self administer his/her emergency
medication.
Special handling instructions:___________________________________________________________________
NOTE: The health care clinician may use another format (computer printout, letter, etc.) to authorize administration of the
medication. However, all information requested above must be provided.
_____________________________________________ _____________________
_____________
Signature of Health Care Clinician
Date
Phone
PARENT’S PERMISSION
I hereby give my permission for my child (named above) to receive medication during school hours. This medication has
been prescribed by a licensed physician or other health care clinician. I hereby release the Board of Education and their
agents and employees from any and all liability that may result from my child taking the prescribed medication.
____________________________________________ _____________________
_____________
Signature of Parent or Guardian
Date
Phone
(SCHOOL USE ONLY)
Name and title of person(s) designated by principal to administer medication:
__________________________________________________________________________________________
__________________________________________________________________________________________
Student has demonstrated to the school nurse the skill to self administer his/her emergency medication.
Content reviewed by:
__________________________________________________
Signature of School Health Nurse
Date
Withdrawal of authorization was made in writing (attach note from parents) ____________________
Date
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