Student Authorization Sheet For Administration Of Oral Medications At School
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1Archdiocese of Seattle, Office for Catholic Schools
AuThORIzATION FOR ADMINIsTRATION OF ORAL MEDICATION AT sChOOL
Student Name: ___________________________________________________ Birth Date: __________________________
School: __________________________________________________________________ Grade: ____________________
ThIs PORTION TO bE COMPLETED bY ThE PhYsICIAN/DENTIsT
Name of Medication
Dosage
Methods of Administration
Time of day to be taken
_________________________________ __________ __________________________ ____________
If given prn specify the length of time between doses _____________________________________________
Inhalers: ________________________________________________________________________________
Indicate if student must carry on his/her person
Possible side effects of medication ___________________________________________________________
Emergency procedure in case of serious side effects _____________________________________________
I request and authorize that the above-named student be administered the above- identified oral medication in accordance
with the instructions indicated above from _____________ to _______________ (not to exceed current school year) as there
exists a valid health reason, which makes administration of the medication advisable during school hours.
_____________________ _________________________________________________________
Date of Signature
Physician/Dentist Signature
Phone: ______________________________ Name: ___________________________________________________
Print or Type
Please Note: If samples of medication are to be given, they must be labeled with the name of the student, dos-
age, and time to be given.
ThIs PORTION TO bE COMPLETED bY ThE PARENT/GuARDIAN
I request/authorize the school to administer medication to the above identified student in accordance with the doctor’s instruc-
tions for the period from _____________to _____________ (not to exceed current school year). I understand that every
effort will be made by school staff to administer the medication in a timely manner.
Permission to carry inhaler
_____________________ _________________________________________________________
Date of Signature
Parent/guardian Signature
Phone: ______________________ __________________________ E-mail:__________________________________
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