PRESCRIPTION MEDICATION

AUTHORIZATION FORM FOR ADMINISTRATION OF MEDICATION BY SCHOOL PERSONNEL

I hereby authorize school personnel to administer medication as indicated to:

Name ____________________________ Grade _____ Teacher _______________________________

Rx Number _______________________ Medication ________________________________________

Directions: ___________________________________________________________________________

___________________________________________________________________________

Doctor ___________________________ Phone ________________ Pharmacy ___________________

Time medication is given at home ________________________________________________________

Time medication is given at school _______________________________________________________

I UNDERSTAND THAT MY SIGNATURE RELIEVES THE SCHOOL PERSONNEL OF ANY AND ALL LIABILITY RELATED TO THE ADMINISTRATION OF THE PRESCRIBED MEDICATION.

_____________________________________ ______________ _______________________________

Signature of Parent/Guardian Date Phone number where you may be

Reached during school

NON-PRESCRIPTION MEDICATION