Student Medication Authorization Form
Student Information
Student Name
Date of Birth
Grade
School
Medication Information
Medication Name
Dosage
Time(s) to Administer
Route (e.g., oral, topical)
Reason for Medication
Special Instructions
Parent/Guardian Authorization
Parent/Guardian Name
Signature
Date
Physician Information & Authorization (if required)
Physician Name
Phone/Fax
Physician Signature
Date