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