Prescription Medication Authorization/Change Form
All medications that are taken at home AND school must be listed on the form below.
Parent's Full Name
*
First Name
Last Name
Student's Name
*
First Name
Last Name
Teacher
*
Mikenna Strom
Andrew Freeman
Myranda Banos
Hollie Paquin
What type of medication are you adding? (Select all that apply)
Prescription Medication to Be Administered at School
Prescription Medication Given at Home
Over the Counter Medication Authorization for School
Medication to Be Administered at School (Click the + sign to add more medications)
*
Medication Administered at Home (Click the + sign to add more medications)
*
Over the Counter Medication for School
*
Prescription Medication Script OR Picture of Medication Bottle
Parent Signature (required)
*
Submit
Should be Empty: