507.02E2 Tipton Community School District Parental Authorization and Release Form for the Administration of Medication to Students

Student's Full Name: _____________________     Date of Birth: _________________                 

School: ___________________________________________________________

School medications and health services are administered following these guidelines:

• Parent has provided a signed, dated authorization to administer prescription medication and/or provide the health service.  Electronic signatures meet the requirement of written signatures.

• The prescribed medication is in the original, labeled container as dispensed. 

• The prescription medication label contains the student’s name, name of the medication, the medication dosage, time(s) to administer, route to administer and date.

• Authorization is renewed annually and as soon as practical when the parent notifies the school that changes are necessary.

 

___________________        _______        _______    ____________

Prescribed Medication          Dosage           Route         Time at School

 

Special Health Services and instructions, if indicted:

____________________________________________________________________________

____________________________________________________________________________ 

Administration instructions

 

____________________________________________________________________________

____________________________________________________________________________  

Special Directives, Signs to Observe and Side Effects

 

_____/_____/_____ 

Discontinue/Re-Evaluate/Follow-up Date

 

 

__________________________                _____/_____/_____ 

Prescriber’s Signature                                     Date

And credentials (when indicated for health service delivery)

 

 

______________________________                ____________ 

Parent's/Guardian Signature                                 Date

 

 

______________________________                ____________

Parent/Guardian address                                    Home/Cell Phone

 

 

______________________________                _____________

Additional Information                                          Business Phone

 

Cross References:

    603.3        Special Education

    607.2        Student Health Services

    607.2R1    Student Health Services - Regulation

 

Approve:  2/10/1997        Reviewed: 08/14/2023        Revised:  08/14/2023