AUTHORIZATION FOR THE ADMINISTRATION OF MEDICATION

BY SCHOOL PERSONNEL

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

Name ___________________ Grade _____ Teacher _________________

Rx Number _________________ Name of Medication ________________

Directions ___________________________________________________________

Doctor _______________ Phone ___________ Pharmacy ____________

Time medication is given at home _________________________________

Time medication is to be 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

Medication Authorization

Student Name ________________ Grade _____ Teacher ______________

Name of Medication Date Given Time Given Signature of Person Giving Medication