School Medication Release Form

Short-term Procedures (one month or less)

  1. Complete the Authorization for Medication Administration form. The Physicians' Statement is not required for short-term medication.
  2. Provide the medication to the school in the prescription bottle which is clearly marked with:
  • Name of pupil
  • Name of prescribing physician
  • Name of medication and a prescription number
  • Name of pharmacy dispensing the medication
  • Amount of the medication to be taken at specified times and/or the specific situations in which it is to be taken

    Long-term Procedures (longer than one month)

  1. Complete the Authorization for Medication Administration form.
  2. Submit the completed Physician's Statement form with the physician's name and signature. The physician may fax this form to the school at the number indicated on the form.
  3. Provide the medication to the school in the prescription bottle which is clearly marked with:
    • Name of pupil
    • Name of prescribing physician
    • Name of medication and a prescription number
    • Name of pharmacy dispensing the medication
    • Amount of the medication to be taken at specified times and/or the specific situations in which it is to be taken

General Information

  1. Medication will not be retained at school from year to year.
  2. Each school year the request form must be renewed.

3. All over-the-counter medication will require a doctor's authorization.

Click on the links below for the Physician's Statement and the Authorization for Medication Administration. Thank you for complying with the above requests. It if felt that following these procedures will enable us to administer medication to your child(ren) promptly and safely.

Physician's Statement

Authorization for Medication Administration

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