Medication Authorization Form

Medication Authorization

Name of Student________________________________________________________________

School _____________________________________Grade_____ School Year________________

Medication_________________________________________________ Dosage______________ 

Time to Dispense_________________________________________________________________

    Purpose______________________________________________________________________

Name of Prescribing Physician______________________________________________________

Physician Number________________________________________________________________

I hereby give my permission for _____________________________________________________

To take the above medication at school as ordered.  I understand that it is my responsibility to furnish this medication and bring it to school.

I hereby request that my child is given the above medication while in school and away from school to official activities.  I understand that the medication may be given by non-medical personnel.  I give my permission for the appropriate personnel to communicate with my Childs’s physician and /or pharmacist in the matter related to medication and health supervision.  I understand that medication and administration will not begin until this form is on file and personnel have received instruction concerning the administration of medication.  I understand and agree that the School Board of Campbell County, its officers, agents, and employees are not responsible for the effects of the medication administered.

I understand that must notify the school in writing of any changes in my child’s condition, medication, or dosages.  I further understanding that I am responsible for ensuring that medication safely arrives at school and for getting refills of the medication as indicated.

____________________________               _______________________________

Date                                                                Signature of Parent/ Guardian

_____________________________              _________________________________

Address                                                           Home Telephone / Cell Telephone

Note:  Prescription medication is to be brought to school in the original container appropriately labeled by the pharmacy or physician stating the child’s name, name of prescribing physician or dentist, name of the medication, dosage, and time to be given.  Non -prescription medication is to be brought to school in the original container with all labels intact.  A new permission form must be completed at the beginning of each school year.

A parent’s or guardians signature is required for prescription and non-prescription medications.

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Amy Abell,
Sep 5, 2018, 5:12 AM
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