Authorization and Informed Consent for Administration of Medication at School

Procedure Name

Form Sections

Section 1info grid

School Name / District

Student Athlete / Pupil Full Name

Date of Birth

Grade / Classroom

Medication Name and Strength

Dosage and Route

Timing / Frequency of Administration

Prescribing Physician

Physician Contact Phone

Section 2text block

Section 3list block

Section 4list block

Section 5list block

Section 6text block

Section 7text block

Section 8text block

Section 9text block

Section 10text block

Section 11text block

Section 12signature block

Parent or Legal Guardian Signature

Prescribing Physician Signature

School Nurse Signature

Date and Time of Consent

Authorization and Informed Consent for Administration of Medication at School

Student and Medication Details

School Name / District

Student Athlete / Pupil Full Name

Date of Birth

Grade / Classroom

Medication Name and Strength

Dosage and Route

Timing / Frequency of Administration

Prescribing Physician

Physician Contact Phone

Nature and Purpose of School Medication Care

This form authorizes the school nurse, health aide, or designated school staff to administer prescribed medication to a student during the school day, or authorizes the student to self-carry and self-administer medication (such as an asthma inhaler or epinephrine auto-injector) as permitted by state laws and district policy. All medications must be delivered to the school in their original pharmacy container, clearly labeled with the student's name, medication name, dosage instructions, and expiration date. Over-the-counter medications also require a physician's signature in most districts.

Optional Student Self-Carry Authorization

[ ] I authorize my child to self-carry and self-administer their rescue medication (e.g. Albuterol inhaler / EpiPen) at school. I confirm that my child has been instructed on how to use the device safely.

[ ] I do NOT authorize self-carry; all medication must be kept in the school health office and administered by staff.

I understand that a duplicate rescue medication must be kept in the school health office even if my child is authorized to self-carry.

Risks and Disclosures

Medication side effects: the student may experience expected side effects of the medication. The school nurse will monitor the student but is not a physician.

Missed dose: while the school makes every effort to administer medication at the scheduled time, the student shares responsibility for coming to the health office.

Sharing medication: students authorized to self-carry must not share or distribute their medication to any other student. Sharing prescription drugs is a serious disciplinary violation.

Alternatives to School Administration

Adjusting the dosing schedule: working with the prescribing physician to schedule doses before and after school hours, eliminating the need for school administration.

Parent administration: the parent coming to school to administer the medication directly to the student.

Emergency Epinephrine and Albuterol Protocol

In the event of a life-threatening emergency (severe anaphylactic allergic reaction or acute asthma attack) where the student is unable to administer their own rescue medication, the school nurse or trained staff will administer emergency epinephrine (EpiPen) or albuterol and immediately call 911. Parents will be contacted as soon as emergency services are notified.

Right to Withdraw Authorization

The parent or legal guardian has the right to withdraw this medication authorization at any time by submitting a written request to the school nurse. Any remaining medication must be picked up by the parent; it will not be sent home with the student.

Parent and Physician Understanding

We confirm that we have completed this medication authorization accurately. We understand that the school is acting in an administrative capacity to support the student's health. We agree to supply all needed medication and to notify the school of any changes in prescription.

Language Access

If English is not your primary language, a qualified interpreter is available at no cost. Please inform the school before signing.

Copy of Consent Acknowledgment

I acknowledge that I have been offered a copy of this signed consent form.

Parental Consent and Authorization

I voluntarily authorize school staff to administer the medication listed above to my child during school hours, or authorize my child to self-carry as selected. I agree to indemnify and hold harmless the school district and staff from any claims arising from the administration or self-administration of this medication.

Signatures and Verification

Parent or Legal Guardian Signature

Prescribing Physician Signature

School Nurse Signature

Date and Time of Consent

Document ID: CC-PENDING

CONSENTCOLLECT