ELEMENTARY Medication Authorization
Parents and guardians may use either this form or the paper medication authorization form to authorize school staff to administer prescription and over the counter medications.  This form may be used for a new medication as well as a change in current medications. 
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Email *
Student First and Last Name and Date of Birth *
Medication *
Reason for Giving this Medication *
Dose  *
Time to be given at school (ie: as needed, lunchtime, specific time)  *
How long does your child need this medication? *
Medication Requirements: 
Non-prescription / Over the Counter: Medication shall be in the original manufacturer's container that includes medication name, strength, and directions for administering.  

Prescription medications: Medication MUST be in the original container as dispensed by the pharmacy. The prescription label must contain the student’s name, name of the medication, prescribing provider, directions for use, and date.  
 *
Required
By providing your name below,  you are authorizing dispensation of the medication by an authorized staff member. PLEASE PROVIDE YOUR FIRST AND LAST NAME IN THE FIELD BELOW.
 *
A copy of your responses will be emailed to the address you provided.
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