Fill and Sign the Authorization to Administer Medicine to Student at School Patient Consent Form

Authorization to Administer Medicine to Student at School NOTE: Medications cannot be administered at _______________________ _________________________________________________ (Name of School) without a Doctor’s written order and a written request from the parent or guardian of the student. Name of Student: _______________________________________________________ Date of Birth: __________________ Address: _____________________________________________________________ School Time Emergency Phone: __________________________ School: _______________________________________________________________ Grade: ________________ Physician’s Statement 1. Name/type of medication: ____________________________________________ 2. Dosage/amount to be given: __________________________________________ 3. Method of administration: ___________________________________________ 4. Frequency and time of administration: _________________________________ 5. Duration (week, month, indefinite, etc.): ________________________________ 6. Diagnosis, Intended Effect and Anticipated Reaction to medication (symptoms, side effects, etc.) : _______________________________________________________________________ _______________________________________________________________________ 7. Other medication(s) child is receiving: _______________________________________________________________________ _______________________________________________________________________ 8. Other requirements: _______________________________________________________________________ _______________________________________________________________________ 9. Must this medication be administered during the school day in order to allow the student to attend school? _____________________________________________ 10. Telephone Number of Physician: _______________________________________ Witness my signature this the _____ day of ________________________, 20___. ______________________________ Name of Physician Parent’s Request and Approval I hereby request and grant permission for personnel of ______________________ ________________________________________________________ (Name of School or School District) , which may include registered nurse, principal, teacher or other staff to administer and/or supervise the self-administration of medication for my child according to the above instructions. I agree not to hold the school district, its officers and employees liable for any claims arising from the administration or supervision of this medication. Witness my signature this the _____ day of ______________________________, 20___. ______________________________ Name of Parent or Guardian