Student Medication Administration Consent Form
Student Information
Student Name
Date of Birth
Grade
School
Medication Information
Medication Name
Dosage
Route (e.g., oral, topical)
Time(s) to be Administered
Reason for Medication
Special Instructions
Parent/Guardian Consent
I authorize the school staff to administer the above medication to my child as specified above. I understand that all medications must be delivered to the school in the original container and appropriately labeled.
Parent/Guardian Name
Signature
Date
Healthcare Provider Authorization (If Required)
Provider Name
Signature
Date
Provider Phone