Student Medication Authorization Form
Student Information
Student Name
Date of Birth
Grade
Homeroom Teacher
Parent/Guardian Information
Parent/Guardian Name
Phone Number
Email Address
Medication Information
Medication Name
Dosage
Time(s) to be Administered
Method of Administration
Reason for Medication
Special Instructions
Authorization
I authorize the school personnel to administer the above medication to my child as directed.
Parent/Guardian Signature
Date
Physician Authorization (if required)
Physician Name
Physician Phone
Physician Signature
Date