Medication Authorization
Submit one form per prescription medication your student needs during the school day, and update it if anything changes.
Student and Parent Information
Student Name
*
Student Grade
*
Please Select
K
1
2
3
4
5
6
7
8
9
10
11
12
Parent/Guardian Name
*
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Medication Details
Medication Name (as it appears on container)
*
Dose and how it is taken
*
What form does it take?
*
Pill/tablet
Liquid
Inhaler
Injection
Other
When is it needed during the school day?
*
How long will this be needed?
*
Ongoing for the school year
Short-term
Last day needed
*
-
Month
-
Day
Year
Date
Prescriber's name and phone number
*
Medication Handling and Authorizations
How will this medication be handled?
*
My student will carry and self-administer it
This medication needs an arrangement with the school
Please note: self-carry is not available for controlled substances (including ADHD/stimulant medications). If your student's medication is a controlled substance, please select 'This medication needs an arrangement with the school' and we will arrange handling with you.
Self-Carry Authorization I authorize my student to carry and self-administer the medication described above during the school day and at school activities. My student understands that this medication must remain in their possession, may never be shared with or given to another student, and must be carried in its original labeled container. I am responsible for ensuring my student carries an adequate, unexpired supply. I understand BSCS staff are not responsible for reminding my student to take this medication, and I release BSCS and its staff from liability related to my student's self-administration of this medication.
Parent/Guardian Signature
*
Medication Administration Agreement I request and authorize BSCS staff to administer the medication listed above to my student. I understand that BSCS does not have a school nurse, and that medication will be administered by designated staff members. I agree that BSCS can only accept and administer medication that is provided in its original pharmacy or manufacturer packaging with the label intact, and will administer it only as directed on that label. Medication that arrives in baggies, pill organizers, or unlabeled containers cannot be accepted. Any change in medication, dose, or timing requires updated packaging and written notice to the school — staff cannot administer based on verbal instructions from a parent or student. I am responsible for supplying the medication, keeping it current (not expired), and collecting any remaining medication at the end of the school year. I understand BSCS may decline to administer a medication if staff have questions about the instructions, and will contact me if that occurs. I release BSCS and its staff from liability for administering medication in accordance with this authorization and the label instructions.
Parent/Guardian Signature
*
I agree to notify the school promptly of any change in this medication, its dose, or its schedule.
*
I agree
Submit
Submit
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