507.2E2 Parental Authorization and Release Form for the Administration of Medication or Special Health Services to Students

  PARENTAL AUTHORIZATION AND RELEASE FORM FOR THE ADMINISTRATION 

OF MEDICATION OR SPECIAL HEALTH SERVICES 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 special health services listed. Electronic signatures meet the requirement of written signatures.
• The prescribed medication is in the original, labeled container as dispensed. 
• 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

And credentials (when indicated for health service delivery)

 ____________________________________________    ___________ / ___________ / _____________                                             

Parent/Guardian Signature                                                                                Date

_______________________________________        __________________________

Parent/Guardian address                                                    Home phone

PARENTAL AUTHORIZATION AND RELEASE FORM FOR THE ADMINISTRATION 

OF MEDICATION OR SPECIAL HEALTH SERVICES TO STUDENTS

 

                                    /    /    

Parent's Signature                        Date

 

                                            

Parent's Address                        Home Phone

 

                                            

Additional Information                        Business Phone

                                                

        

                                                

 

                                                

Authorization Form