2023-2024 Authorization for Administration of Medication at School

Authorization for Administration of Medication at School

Hamilton Community Schools 903 South Wayne Street Hamilton, IN 46742 Phone: 260.488.2101 Fax: 260.488.3149
Student Name*

First NameLast Name
Grade*
Teacher
Medication
Dose
Time of Administration
AM/PM
Date Medication to be discontinued

MonthDayYear
Date
Student Name - has permission to bring this medication home:
Parent/Guardian Initials
Responsible Adult - an adult (18) years of age or older, has my permission to bring this medication to me:
Parent/Guardian Initials
By MouthInhaledPatchInjectionOther
Medical Condition
- I assume the responsibility for the safe transport of this medication to school.
- I request the medication be given on field trips, as prescribed.
- I release school personnel from liability should administering this medication result in an adverse reaction.
- I will notify the school, in writing, of any change in the medication (dosage change, med discontinued, etc.
- I give permission for the school nurse to communicate with student’s teacher, physician, and necessary school staff about child’s health condition and the action of the medication.
- I give permission for the medication to be given by the designated personnel (the school nurse may not always be present in the school).
- I certify that I am the parent, legal guardian, or other person in legal control of the above identified student. I read and understand the information within this authorization and the procedure for administration of medication at school.
(Telephone Number)
Format: (000) 000-0000.
Enter Name in lieu of Signature

First NameLast Name
(Date)

MonthDayYear
Date
Should be Empty: