Prescription Medication Authorization Form
Students are not permitted to have medications in their possession while on the school campus. If a medication needs to be taken while at school, the student must come to the office to obtain it from an administrator. With certain medical conditions, (e.g., diabetes, asthma, severe allergy) emergency medications may be kept in the classroom with the teacher, and records will be kept of all medications administered.  

All prescription and over the counter medications must be in the original container and labeled by the manufacturer or pharmacist. Medications will not be given from an envelope or plastic bag. The label must include:

Student’s Name
Exact Dosage of Medication
Physician’s Name
Date Prescription filled
Name of Medication
Expiration Date of Medication

 
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Student's Last Name *
Student's First Name *
Student's Date of Birth: *
MM
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DD
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YYYY
Student's Grade *
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