Medication Authorization Form - Non-Prescription
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1Medication Authorization Form – Non-prescription
S
______________________________
G
______________
TUDENT
RADE
Student
S
_______________________________
B
___________
CHOOL
IRTHDATE
A
(M
) ________________________________________
LLERGIES
EDICATIONS
As parent/guardian of the above named student, I request the School District to give medicine for the following
condition(s). This medication request must be deemed necessary to maintain or improve health and participation in the
school program. Each request will be assessed for the most appropriate intervention and will be given at the standard
dosage recommended by manufacturer. (Check all that apply)
C
:
Headache
Cramps
Dental
Other: __________________________
ONDITION
M
:
Acetaminophen
Ibuprofen
Naproxen
Midol/Premsyn/Pamprin
Other______________
EDICINE
Dose: ___________
Frequency: _____________(if less than manufacturer’s recommended dose)
Specify Time: ____________ or As Needed: ____________________Side Effects________________________________
Special Instructions for Administration__________________________________________________________________
I understand that the school is not legally obligated to administer medication to my child. Therefore, I agree to defend
and hold harmless, the school district and its employees from any liability for the results of the medication or the
manner in which it is administered, and to defend and indemnify the school district and its employees for any liability
arising out of these arrangements.
I understand that in the absence of the school nurse, other trained school staff will administer
I will notify the nurse if I give this medication to my child before arrival at school while this request is
the medication.
in effect to prevent overmedicating. I also affirm that my child has taken this medicine at least two times in the past
without any adverse side effects. I agree to supply medication for my student in its original packaging (small bottles
only, please). I understand that the medicine will be destroyed unless picked up by the end of the last student school
day of this year. Medicines will not be kept by the school over the summer break per DEA regulations.
Parent/Legal Guardian Signature: __________________________ Printed Parent Name: _____________________
Date: _________________
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Initials_______
Name ____________________________
Initials_______
Name ____________________________
Initials_______
Name ____________________________
Initials_______
Name ____________________________
School Nurse Signature____________________________Date____________________
Phone _____________ Fax ____________Email ________________________________
Adapted from Anchorage School District form 8-2012, revised 9-2013
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