Medication Authorization Form

Note: It is necessary to complete this form ONLY if your son/daughter is on daily/scheduled medication or has a need for PRN emergency medication.

Student's Name*

Please check one:*

Name of Medication*

Dosage and Frequency*

Please note how much medication you are providing to the school:*

All prescription drugs must be in the labeled container as received from the pharmacy.

All over-the-counter medication must be in the originally purchased and labeled container and will be administered only with written or phone instructions from a parent or physician.

Please list any additional comments/instructions/questions here:

Parent Name (which acts as your signature)*

Today's Date*

This form is being submitted for the following school year:*