Medication Authorization Form printable pdf download

To be updated by parent/guardian/physician annually

MEDICATION AUTHORIZATION FORM

______________________________________________ SCHOOL, ________________________, ILLINOIS

________________________________

_________________

_____

__________

Student Name (Last, First, Middle)

Date o

f B

irth

Grade

Date

Medications may be administered in school in accordance with the School Medication Procedures.

No medication may be administered in school unless both the student’s physician and parent/guardian

have completed, signed, and returned this entire form to the School and the Medication in the original

labeled container as dispensed (prescription medication) or the manufacturer’s labeled container (non-

prescription medication). The medication label shall contain the student’s name, name of the

medication, direction for use and date.

Parent/Guardian Permission and Authorization

I hereby acknowledge that I am primarily responsible for administering medication to my child.

However, in the event that I am unable to do so or in the event of a medical emergency, I hereby

authorize the School Principal or his/her designee, on my behalf, to administer or to attempt to

administer to my child (or to allow my child to self-administer in accordance with School Medication

Procedures), lawfully prescribed medication and non-prescribed medication in the manner described

in the Physician’s Order {Reverse side}. I acknowledge that it may be necessary for the

administration of medications to my child to be performed by an individual who does not have

medical training, and I specifically consent to such practices.

I understand that this authorization is not effective unless the School Principal or his/her designee has

approved the medication authorization for my child and signed this form in the space provided below.

I further acknowledge and agree that, when such medication is to be administered or attempted to be

administered, I waive any claims I might have against the School, the Catholic Bishop of Chicago, the

parish, or any of their employees or agents arising out of the administration or attempted

administration. In addition, I agree to hold harmless and indemnify the School, the Catholic Bishop of

Chicago, the parish, and their employees or agents, either jointly or severally, from and against any

and all claims, damages, causes of action or injuries incurred or resulting from the administration or

attempted administration of said medication.

_______________________________

________________________________

Parent/Guardian (PRINT)

_______________________________

________________________________

Parent/Guardian (SIGNATURE)

_______________________________

________________________________

Address

_______________________________

________________________________

City, State, Zip Code

_______________________________

________________________________

Home Phone

Business Phone

Home Phone

Business Phone

Archdiocese of Chicago

Medical Authorization Form

Office of Catholic Schools

PARENT/GUARDIAN COPY

June 2008

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Medication Authorization Form

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