AUTHORIZATION FOR PRESCRIBED MEDICATION/DRUG OR TREATMENT

To the Parent:

THE FOLLOWING INFORMATION IS NECESSARY FOR ANY STUDENT TO USE PRESCRIBED MEDICATIONS OR TO RECEIVE TREATMENT IN SCHOOL. ALL SPACES MUST BE COMPLETED.

Name of Student	Address

School	Grade

A.	I am requesting permission for my child named above to: (Check all that apply)

 	_	use or receive prescribed medication

 	_	receive prescribed treatment

 	_	self-administer prescribed medication(s) in my presence or that of an authorized staff member

 		for student with diabetes only: self-administer diabetes care in accordance with Policy 5336

in accordance with the Doctor’s prescription.

B.	I will assume responsibility for safe delivery of the medication/drug to school, except for diabetes medication student is permitted to posses pursuant to Policy 5336.
C.	I will notify the school immediately if there is any change in the use of the medication/drug or the prescribed treatment, or if I wish to revoke this authorization.
D.	I release and agree to hold the Board of Education, its officials, and its employees harmless from any and all liability for damages or injury resulting directly from this authorization.

 	_

Signature of Parent	Date

 	_

Home Telephone	Work Telephone

LICENSED PRESCRIBER'S STATEMENT

To the Prescriber:

The School District requires that all of the following information be provided before it will administer medication or treatment to the student named on this form.

I have prescribed the following medication  	

 	_

 		_ Beginning Date 	_ Ending Date  		
Dosage, instructions, or precautions (including possible side effects):  	

 	_

 	_

 	 _ I have prescribed the following treatment 	_
 	_

 	_

 	_

 	_

 			_ Beginning Date 	_ Ending Date 	_ For student with diabetes only:
        _ I authorize the student to attend to his/her diabetes care and management,  in  accordance with my order, during regular school hours and school sponsored activities. I have determined that the student is capable of performing diabetes care tasks.

 	_	I do not authorize the student to attend to his/her diabetes care and management during regular school hours and school sponsored activities.

Prescriber’s Signature 	_ Telephone  	

Printed/Typed Name 	_ Date 	_

AUTHORIZATION FOR STAFF

The	following	staff	members	are	authorized	to	administer	the	above-prescribed medication(s)/treatment(s):

 	_

 	_

Principal