AUTHORIZATION TO ADMINISTER MEDICATION IN SCHOOL  
(TO BE KEPT CONFIDENTIAL UPON COMPLETION)

NAME OF STUDENT:  _______________________________ Grade ____________  
 

DIAGNOSIS/ILLNESS: ____________________________________________  

MEDICATION: __________________________________________________  
 

DOSAGE: ______________________  FREQUENCY:  ___________________  
 

SPECIAL DIRECTIONS:____________________________________________  
 

POSSIBLE SIDE EFFECTS: _________________________________________                              

I certify that the above information regarding this Student is correct, and that administration of the medication to this  Student is necessary. 

_________________________________________         _______________________
(Signature of Prescribing Physician)                                                 (Date)

________________________________________           _______________________ (Address)                                                                                   (Phone)  

I/We authorize the School Nurse or, in his/her absence, the Principal to administer the above medication as indicated.  I/We understand and agree that the School, the School Nurse and the Principal shall not be liable for any injury to the Student resulting from the administration of the medication as authorized by my signature below. 

_____________________________________
(Signature of Parent/Guardian)  

___________________________________________
(Signature of Parent/Guardian)      

___________________________________________
(Date)