AUTHORIZATION FOR ADMINISTRATION OF ORAL MEDICATION AT SCHOOL
Student Name: ______________________________________________     Birthdate: __________________________
School: ____________________________________________________      Grade: ____________________________
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THIS PORTION TO BE COMPLETED BY THE LICENSED HEALTH PROFESSIONAL (LHP) PRESCRIBING WITHIN THE SCOPE OF THEIR PRESCRIPTIVE AUTHORITY
Name of Medication	Dosage	Methods of Administration	Time of day to be taken
_____________________	_____________	________________________	________________
_____________________	_____________	________________________	________________
Diagnosis or reason for medication _______________________________________________________
If given PRN, specify the length of time between doses ________________________________________
Inhalers __________________________________________________________________________________
Indicate if student carry on his/her person
Student is capable of self-administration of medication _________Yes ________No
Possible side effects of medication_____________________________________________________
Emergency procedure in case of serious side effects______________________________________
I request and authorize that the above-named student be administered the above identified oral medication in accordance with the instructions indicated above from _____________________(date) to _________________________(date) (not to exceed current school year) as there exists a valid health reason which makes administration of the medication advisable during school hours.
__________________________________________		______________________________________________
Date of signature		Licensed health professional
__________________________________________		______________________________________________
Telephone Number		Name (Print or type)
Please note: If samples of medication are to be given, they must be labeled with the name of the student, dosage, and time to be given.
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THIS PORTION TO BE COMPLETED BY THE PARENT/GUARDIAN
I request/authorize the school to administer the medication to the above identified student in accordance with the LHP's instructions for the period from ______________ to _______________ (not to exceed current school year). I understand that every effort will be made by school staff to administer the medication in a timely manner.
Permission to carry inhaler __________ Yes _____________No
Permission to self-administer medication __________ Yes _____________No
_______________________________		_____________________________________________
Date of signature		Signature of parent/guardian
Telephone Number _______________________ (home) _____________________________ (work)
Adapted with permission from a form developed by the Central Valley School District