507.2E2 PARENTAL AUTHORIZATION AND RELEASE FORM FOR THE ADMINISTRATION OF PRESCRIPTION MEDICATION TO STUDENTS

Student's Name (Last), (First) (Middle)                                                                                            

Birthday ___/___/___

School                                                                                                                                                 Date ___/___/___

School medications and special health services are administered following these guidelines:

• Parent has provided a signed, dated authorization to administer prescription medication and/or provide the special health services listed.  Electronic signature meet the requirement of written signatures..
• The prescribed medication is in the original, labeled container.
• The prescription medication label contains the student's name, name of the medication, the medication dosage, time(s) to administer, route to administer, and date.
• Authorization is renewed annually and as soon as practical when the parent notifies the school that changes are necessary.

Prescribed Medication                                                                                      Dosage                             Route                             Time at School                            

Special Health Services and instructions, in indicated: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

                               /                      /                        

    Discontinue / Re-Evaluate / Follow-up Date for Prescribed Medication or Special Health Services listed

Prescriber's Signature                                                                                        Date ___/___/___

Add credentials (when indicated for health service delivery

Parent/Guardian Signature and Date:

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PARENTAL AUTHORIZATION AND RELEASE FORM FOR THE ADMINISTRATION OF MEDICATION OR SPECIAL HEALTH SERVICES TO STUDENTS

Parent/Guardian Signature                                                                                   Date ___/___/___

Parent/Guardian Address                                                                                                    

Business Phone                                 Home Phone                                

Additional Information