Sample Parent/Guardian Authorization
For Prescription Medication Administration

Student’s name__________________________________________________________________

Parent/Guardian printed name______________________________________________________

Telephone number—Home:___________________	Cell Phone number ________________

Telephone number—Work:_________________________

Telephone number—Emergency:____________________

Other person(s) to be notified in case of medication emergency:

   Name:_______________________________  Telephone number:____________________

My son/daughter is currently receiving the following medications (to be completed if not in violation of confidentiality):

My son/daughter has the following food or drug allergies:

I consent to have the school nurse or school personnel designated by the School Nurse administer the medication prescribed by:

_______________________________________   to ___________________________________
       Licensed Prescriber                                              Student’s Name

I give permission for my son/daughter to self-administer medication, if the school nurse determines it is safe and appropriate.
      _____Yes    _____No

I give permission to the School Nurse to share information relevant to the prescribed medication administration as he/she determines appropriate for my son’s/daughter’s health and safety.

I understand I may retrieve the medication from the school at any time; however, the medication will be destroyed if it is not picked up within one week following termination of the order or one week beyond the close of school.

Parent/guardian signature_________________________________________
Relationship to Student____________________________________________

Address:__________________________________________________________