AUTHORIZATION FOR THE ADMINISTRATION OF MEDICATION

Name of Student___________________________ Birthdate_____________________

Address__________________________________ Phone_______________________

School_____________________ Grade________________ Teacher______________

Physician’s Statement:

1. Name/type of medication__________________________________________

2. Dosage/amount to be given________________________________________

3. Frequency/times to be administered__________________________________

4. Duration (week, month, indefinite, etc.)_______________________________

5. Anticipated reaction to medication (symptoms, side effects, etc.)___________

_______________________________________________________________

Physician’s Signature____________________________________________

Date__________________________________________________________

Physician’s Address____________________________________________

Physician’s Phone______________________________________________

Parent/Guardian Request/Approval:

I hereby request and give my permission for the above-named school to administer the medication prescribed on this form to my child.

_________________________________________ _________________

Parent/Guardian Signature Date

Designated Person(s) Administering Drugs:

I have agreed to administer the medication as requested by the parents and in accordance with directions listed above by the physician.

_________________________________________ __________________

Signature of person administering medication Date