School Authorization for Administration of Medication

St. Bartholomew School Health Office

Authorization for Administration of Medication at School (Short-Term)
In order to give medication (over-the-counter) during school hours, parents need to:
- Complete this medication authorization form including a parent e-signature authorizing staff to dispense medication
- Send over the counter medication in the original container labeled with student name, dosage and time medication should be given
- Medication is to be given on a short-term basis (14 days or less) and is non-narcotic
General Note: Parents/Guardians will be contacted, if possible, prior to any medication being given.
Student Name*

First NameLast Name
Grade/Teacher*
Parent Name*
Parent E-mail*
Start Date*

MonthDayYear
Authorization will expire 14 days from Start Date
Medication*
Requested Dosage
Reason for Medication*
Student's Approximate Weight
I, {parentName}, hereby give permission for my child to receive the above mentioned over the counter medication at school. I agree the dosage given will be based on the Directions listed on the medication packaging according to my child's age and weight. I authorize reciprocal release of information related to the medication between the school nurse and the prescribing health professional should communication be necessary.
I Agree*

I have read, understood, acknowledge and confirm that the information is true and correct
E-Signature*

Clear
Should be Empty:

St. Bartholomew School Health Office