Medicine Distribution Authorization Form 7-12

PARENTAL AUTHORIZATION TO ADMINISTER MEDICINE

Grades 7-12
HOOKER BOARD OF EDUCATION

FFACA-E2
Date *

Month Day Year
Date
Date2

Month Day Year
Date
Student Name *

First Name Last Name
Student Name2

First Name Last Name
Student Name3

First Name Last Name
Student Name4

First Name Last Name
Student Name5

First Name Last Name
Student Name6

First Name Last Name
Grade: *
Grade:2
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Address2

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Home Phone Number *

Area Code Phone Number
Home Phone Number2

Area Code Phone Number
Work Phone Number

Area Code Phone Number
I am the parent with legal custody, the legal guardian, or individual assuming permanent care and custody, of the above student attending this school. This student requires medication at intervals during the school day. I hereby give my consent and authorize and request the school principal, or an employee of the school district designated by the principal to: Check all that apply: *

Administer the above student a non-prescription medication which I am hereby supplying you, in accordance with the label directions or written instructions from the student’s physician which is attached hereto. Non-prescription medication must be in original container and will only be given if supplied by parent or guardian. Administer the above student a filled prescription medication which I am hereby supplying you, in accordance with the directions for the administration of the medicine listed on the label of the vial. Medication must be in its original prescription container or a package from the doctor’s office. Administer the above student a filled prescription medication which I am hereby supplying you, in accordance with the written instructions of the physician prescribing the medicine, which is attached hereto. Medication must be in its original prescription container or a package from the doctor’s office Permit the above student to retain prescribed medication on the student’s person, such as inhalers, EpiPens, and diabetic supplies, since the medication must be administered at unpredictable intervals throughout the day.
I understand that under state law, the board of education, the school district, or the employees of the district shall not be liable to the student’s parent or guardian for civil damages for any personal injuries to the student which result from acts or omissions of school employees in administering the medicine I have hereby authorized.
Please list any known allergies for this student:
Allergies2:
AUTHORIZATION FOR MEDICAL CARE OF MINOR
We, the parents of the above student in Hooker Schools, give consent for the student to have any x-ray examination, medical, surgical or dental diagnosis or treatment and hospital care deemed necessary upon the advice of a physician, surgeon or dentist licensed under the laws of the State of Oklahoma. GIVING THIS CONSENT I RECOGNIZE AND UNDERSTAND that in situations where the above named student requires immediate medical or hospital care it may not be possible to contact me, and that in such situations I will not be able to knowledgeable evaluate and choose among the available alternative treatments or procedures, if any, or to evaluate the risks attendant upon each, and the risks attendant to foregoing all treatments; in such situations, I authorize a physician, surgeon or dentist to exercise his professional judgment and assess the risks incident to and choose the necessary treatment from any available alternatives and to render such care and perform such treatment as he in his professional judgment determines to be necessary for the health and safety of the above named student.
PARENT'S INSURANCE COMPANY
POLICY NUMBER
PERSONS TO BE NOTIFIED (OTHER THAN PARENT/GUARDIAN) IN AN EMERGENCY AND RELATIONSHIP
Name: *

First Name Last Name
Phone Number *

Area Code Phone Number
Name: *

First Name Last Name
Phone Number *

Area Code Phone Number
*******TREATMENT INFORMATION
FAMILY DOCTOR *
Phone Number *

Area Code Phone Number
STUDENT'S BIRTHDATE: *

Month Day Year
Date
STUDENT'S SOCIAL SECURITY NUMBER (Optional):
DATE OF LAST TETANUS SHOT. IF NOT KNOWN, WRITE DON'T KNOW. *
MEDICATIONS CURRENTLY TAKING
NAME OF HOSPITAL EMERGENCY PREFERRED *
Heart Condition or Disease *

Yes No
Diabetes *

Yes No
Convulsions Disorder *

Yes No
Asthma *

Yes No
Allergic Medication *

Yes No
Allergic to Insect Stings *

Yes No
If you chose yes on any option(s), please give needed information or provide other medical history information if needed
Should be Empty:

PARENTAL AUTHORIZATION TO ADMINISTER MEDICINE

HOOKER BOARD OF EDUCATION

AUTHORIZATION FOR MEDICAL CARE OF MINOR

PERSONS TO BE NOTIFIED (OTHER THAN PARENT/GUARDIAN) IN AN EMERGENCY AND RELATIONSHIP

*******TREATMENT INFORMATION