This form is to be used for all medicine brought to school that is to be kept in the office and dispensed by trained school personnel. Please note the following prior to downloading and completing the form.

  1. This authorization form must be completed for all medication dispensed by the office.
    1. Section I must be filled in by the physician completely, then signed and dated before medicine can be dispensed.
    2. Section II must be completed by the parent. This includes the signature and contact information after the paragraph indicating that the parent requests this medication be given during school hours.
      1. The first part of Section II covers parent permission for all oral, inhaled, instilled, or topical medications to be given at school on a routine basis (a set time every day).
      2. The second part of Section II covers parent permission all oral, inhaled, instilled, or topical to be given on a PRN or as-needed basis.
  2. Students with diabetes, severe allergies, and asthma may carry their medications and equipment with them during the school day, only if certain conditions are met and the paperwork is completed. Please talk with the school nurse if your student needs to carry his/her medications/equipment for these conditions only.

Medication Authorization