Medication Permissions

5330 F1/page 1 of 3

PARENT REQUEST AND AUTHORIZATION TO ADMINISTER A PRESCRIBED

MEDICATION/DRUG OR TREATMENT

To the Parent:

THE FOLLOWING INFORMATION IS NECESSARY FOR ANY STUDENT TO USE PRESCRIBED

MEDICATIONS OR TO RECEIVE TREATMENT IN SCHOOL. ALL SPACES MUST BE COMPLETED.

________________________________________ ____________________________________

Name of Student Address

________________________________________ ____________________________________

School Grade

A. I am requesting permission for my child named above to: (Check all that apply)

_____ use or receive prescribed medication

_____ receive prescribed treatment

_____ self-administer prescribed medication(s) in my presence or that of an authorized

staff member

in accordance with the authorized prescription.


B. I will assume responsibility for safe delivery of the medication/drug to school. (The

medication/drug must be received by the District (i.e., the person authorized to administer the

drug to the student) in the container in which it was dispensed by the prescriber or a licensed

pharmacist.)


C. I will notify the school immediately if there is any change in the use of the medication/drug or the

prescribed treatment. (You must submit to the District a revised licensed prescriber's statement,

signed by the prescriber, if any of the information contained in the statement changes.)


D. I release and agree to hold the Board of Education, its officials, and its employees harmless from

any and all liability foreseeable or unforeseeable for damages or injury resulting directly or

indirectly from this authorization.


______________________________________________ ______________________________

Signature of Parent* Date

______________________________________________ ______________________________

Home Telephone Work Telephone

*Parent, guardian, or other person having care or charge of the student


© NEOLA 2006



5330 F1/page 2 of 3

LICENSED PRESCRIBER'S STATEMENT

To the Prescriber:

The School District requires that all of the following information be provided before it will administer

medication or treatment to the student.


___________________________________________ _____________________________

Name of Student Address


__________________________________________ _____________________________

School Class/Grade


I am a licensed health professional authorized to prescribe drugs, and I have prescribed the following

medication to the above named student (specify the name of the drug) _________________________

__________________________________________________________________________________

__________________________________________________________________________________

Date the administration of the drug is to begin _________________________________________

Date the administration of the drug is to cease _________________________________________

Specify the dosage of the drug to be administered, and the times or intervals at which each dosage of

the drug is to be administered ___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

Specify any special instructions for administration of the drug, including sterile conditions and storage

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

Report the following side effects (i.e., severe adverse reactions) to my office immediately

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________


Prescriber’s Signature ______________________________ Telephone ________________________


Printed/Typed Name ________________________________ Date ____________________________

© NEOLA 2006