Code No. 507.2E3
TIPTON COMMUNITY SCHOOL DISTRICT
PARENTAL AUTHORIZATION AND RELEASE FORM FOR INDEPENDENT
SELF CARRY AND ADMINISTRATION OF PRESCRIBED MEDICATION OR
INDEPENDENT DELIVERY OF HEALTH SERVICES BY THE STUDENT
_________________________________ ___/___/___ _________________ ___/___/___
Student's Name (Last), (First), (Middle) Birthday School Date
I request the above-named student (Parent/Guardian initial all that apply)
______ Carry and complete co-administration of prescribed medication, when competency has been demonstrated to licensed health personnel working under the auspices of the school. In accordance with applicable laws, students with asthma, airway constricting diseases, respiratory distress or students at risk of anaphylaxis who use epinephrine auto-injectors may self-administer their medication upon the written approval of the student’s parents and prescribing licensed health care professional regardless of competency. The information provided by the parent for medication administration is confidential as provided by the Family Education Rights and Privacy Act (FERPA) and any other applicable laws. I agree to provide safe delivery of the medication to and from school and to pick up remaining medication at the end of the school year or when medication is expired. If the students abuses the self-administration policy, the ability to self-administer may be withdrawn by the school or discipline may be imposed, after notification is provided to the student’s parent.
____________________________________________________________________________Prescribed Medication Dosage Route Time at School
______ Co-administer, participate in planning, management and implementation of special health services at school and school activities after demonstration of proficiency to licensed health personnel working under the auspices of the school. The information provided by the parent for health service delivery is confidential as provided by the Family Education Rights and Privacy Act (FERPA) and any other applicable laws. I agree to coordinate and work with school personnel and the prescriber (if indicated) when questions arise. I agree to provide safe delivery of the student’s equipment necessary for health service delivery to and from school and to pick up remaining equipment at the end of the school year.
Special Health Services Delivery:
___________________________________________________________________________
___________________________________________________________________________
Procedures for abandoned medication disposal shall be in accordance with applicable laws.
____________________________ ___________________
Prescriber’s Signature Date
and credentials (when indicated for health service delivery)
____________________________ ___________________
Parent/Guardian Signature Date
__________________________ _____________________
Parent/Guardian address Home phone
Cross Reference:
603.3 Special Education
607.2 Student Health Services
607.2R1 Student Health Services - Regulation
Approved: 08/14/2023 Reviewed: _____________ Revised: _______________
