If it becomes necessary for a student to receive prescription medication at school, all sections of this form must be completed before the medication can be given. A separate form is needed for EACH medication.

School medications and health services are administered following these guidelines:
* Parent has provided a signed, dated authorization to administer medication and/or provide the health service.
* The medication is in the original, labeled container as dispensed or the manufacturer's labeled container.
* The medication label contains the student's name, name of the medication, directions for use, and date. (request extra bottle from pharmacy)
* Authorization is renewed annually or immediately when the parent notifies the school that changes are necessary.

Special instructions and/or instructions as they appear on the prescription:

I request and authorize school personnel to administer this medication and/or service. I understand that trained school personnel will administer this medication if the nurse is not available. I understand that I am personally responsible to ensure the medication is received by the school in the container in which it was dispensed by the physician or pharmacist or is in the manufacturer's container. I also ensure that the container in which the medication is dispensed is marked with the correct medication name, dosage, directions for time of administration, and the correct student's name.

Parent/Guardian Signature___________________________________________________________________ Date__________________