Medication Authorization Form

Note: This form must be completed if your son/daughter is on daily/scheduled medication or has a need for PRN emergency medication. This form may also be used for occasional dispensing of required medications during the school day (e.g. prescription antibiotics.)

I hereby give permission for my child listed here to receive the medication noted below during school hours. This medication has been prescribed by a licensed physician. I hereby release the Board of Directors, School Administration and employees of The Fulton School from all liability that may result from my child taking the prescribed medication. This consent is good for the school year designated below, unless revoked in writing. I will furnish all medications for use at the school in a container properly labeled by a pharmacist with identifying information (name, medication to be dispensed, dosage prescribed, and time to be given).*

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:*