Authorization For The Administration Of Medication Form


Authorization for the Administration of Medication by School, Child Care, and Youth Camp Personnel
In Connecticut schools, licensed Child Day Care Centers and Group Day Care Homes, licensed Family Day Care Homes, and licensed Youth Camps
administering medications to children shall comply with all requirements regarding the Administration of Medications described in the State Statutes and
Regulations. Parents/guardians requesting medication administration to their child shall provide the program with appropriate written authorization(s) and the
medication before any medications are administered. Medications must be in the original container and labeled with child’s name, name of medication,
directions for medication’s administration, and date of the prescription.
Authorized Prescriber’s Order (Physician, Dentist, Optometrist, Physician Assistant, Advanced Practice Registered Nurse or Podiatrist):
Name of Child/Student _________________________________ Date of Birth____/____/____ Today’s Date____/____/____
Address of Child/Student _______________________________________________________Town___________________
Medication Name/Generic Name of Drug________________________________________ Controlled Drug?
Condition for which drug is being administered: _____________________________________________________________
Specific Instructions for Medication Administration ___________________________________________________________
Time of Administration _________________________ If PRN, frequency_____________________________
Medication shall be administered: Start Date: _____/_____/_____ End Date: _____/_____/______
Relevant Side Effects of Medication _______________________________________________________
None Expected
Explain any allergies, reaction to/negative interaction with food or drugs__________________________________________
Plan of Management for Side Effects _____________________________________________________________________
Prescriber’s Name/Title ______________________________________________ Phone Number (_____) ______________
Prescriber’s Address _________________________________________________________ Town ___________________
Prescriber’s Signature __________________________________________________________
Date _____/_____/_____
School Nurse Signature (if applicable) ____________________________________________________________________
Parent/Guardian Authorization:
I request that medication be administered to my child/student as described and directed above
I hereby request that the above ordered medication be administered by school, child care and youth camp personnel and I give permission for the
exchange of information between the prescriber and the school nurse, child care nurse or camp nurse necessary to ensure the safe administration of
this medication. I understand that I must supply the school with no more than a three (3) month supply of medication (school only.)
I have administered at least one dose of the medication with the exception of emergency medications to my child/student without adverse effects. (For
child care only)
Parent/Guardian Signature___________________________________ Relationship______________ Date ____/____/____
Parent /Guardian’s Address ____________________________________________Town___________________State_____
Home Phone # (_____) ______-________ Work Phone # (_____) ______-________ Cell Phone # (_____) ______-_______
Self-administration of medication may be authorized by the prescriber and parent/guardian and must be approved by the school nurse (if
applicable) in accordance with board policy. In a school, inhalers for asthma and cartridge injectors for medically-diagnosed allergies,
students may self-administer medication with only the written authorization of an authorized prescriber and written authorization from a
student’s parent or guardian or eligible student.
Prescriber’s authorization for self-administration:
NO _________________________________________________________
Parent/Guardian authorization for self-administration:
NO _____________________________________________________
School nurse, if applicable, approval for self-administration:
NO ________________________________________________
Today’s Date ___________Printed Name of Individual Receiving Written Authorization and Medication _________________
Title/Position _____________________________ Signature (in ink or electronic) __________________________________
Note: This form is in compliance with Section 10-212a, Section 19a-79-9a, 19a-87b-17 and 19-13-B27a(v.)


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