Medication Authorization Form Page 2
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1
2To be updated by parent/guardian/physician annually
Physician’s Order
Student ___________________________________
Grade ____________
____________________________
____________
_______________________________________
Medication/ Health Care Treatment
Dosage
Time(s) to be administered
_________________________________________
______________________________________________
Intended effect of this medication
Expected side effects, if any
__________________________________________________________________________________________
Other medications the student is taking
1
) May student self-administer medication under supervision of school personnel who do not have
medical training?
(Please circle)
YES
NO
2) For ASTHMA and ALLERGY CONDITIONS ONLY:
I certify that this student has been instructed in the use and self-administration of this medication
and is capable of self-administering the medication independently and without supervision.
(Please circle)
YES
NO
I also request that this student be allowed to carry the above-described medication on their person
during school hours and during school-related activities in order to facilitate the self-administration
of the medication as needed.
(Please circle)
YES
NO
Administration Instructions:
________________________________________
________________________________
Physician’s /Prescriber’s Signature
Date Signed
________________________________________
________________________________
Physician’s/ Prescriber’s Name (PRINT)
Emergency telephone number
_________________________________________________________________________________________
Address
City , State, Zip Code
Medication Authorization approved or denied and signed this ____ day of _____________,
(Please circle one)
20 ___, by
on behalf of
____________________________________________________________
Signature of Principal
_________________________________School, _____________________ , Illinois
Archdiocese of Chicago
Medical Authorization Form
Office of Catholic Schools
PARENT/GUARDIAN COPY
June 2008
Page 2 of 2
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