Authorization for administration of medication at school: Immanuel Lutheran #507, Courtland, MN
In order to give medication (prescription or over-the-counter) during school hours, parents will need to

-Complete this medication authorization form including a written physician's order and parent signature authorizing staff to dispense medication.

-If a student needs to carry medication with them (e.g. inhalers, epipens), please have the physician identify this in the written order.

-Send medication in the ORIGINAL container with a pharmacy label identifying student name, drug, dosage, time medication should be given, and physician's name. Over the counter medication must be sent in the original container.

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Email *
Date *
MM
/
DD
/
YYYY
Student's Name and Grade *
Medication *
Dose and Time(s) *
Start Date
MM
/
DD
/
YYYY
End Date
MM
/
DD
/
YYYY
Possible Side Effects
Diagnosis or reason for medication *
If there are special instructions, list them here. Also, if this medication is to be given as needed, please explain when it should be given:
Physician's name/phone number
Parent contact information: daytime phone (work or cell) and home phone *
Parent Authorization for Administration of Medication *
By clicking the box "yes" below I understand that I hereby give permission for my child to receive medication at school as prescribed by child's doctor, nurse, practitioner or dentist. I authorize reciprocal release of information related to the medication between the school nurse and the prescribing health professional.
A copy of your responses will be emailed to the address you provided.
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