QUEEN OF PEACE SCHOOL

PHYSICAN’S AUTHORIZATION FOR ADMINISTRATION

OF MEDICATION BY SCHOOL PERSONNEL

NAME OF STUDENT

NAME OF MEDICATION

DOSAGE

INSTRUCTIONS FOR ADMINISTRATION (ROUTE, TIME, HOW OFTEN?)

SPECIAL STORAGE INSTRUCTIONS

POSSIBLE SIDE EFFECTS

DESCRIPTION OF POSSIBLE REACTION THAT, IF OBSERVED, SHOULD BE REPORTED TO PHYSICIAN

EXPIRATION DATE OF THIS REQUEST

DATE PHYSICIAN’S SIGNATURE

PHYSICIAN’S NAME

PHYSICIAN’S ADDRESS

PHYSICIAN’S TELEPHONE NUMBER

PARENT AUTHORIZATION FOR ADMINISTRATION

OF MEDICATIONS BY SCHOOL PERSONNEL

I AUTHORIZE SCHOOL PERSONNEL TO

(Parent or guardian)

ADMINISTER AS INSTRUCTED BY

(Name of medication)

AND AGREE TO; 1) DELIVER THE

(Name of physician)

MEDICATION TO SCHOOL; 2) TO NOTIFY THE SCHOOL IF I CHANGE PHYSICIANS; 3) TO NOTIFY THE SCHOOL IF THE MEDICATION OR DOSAGE IS CHANGED OR DISCONTINUED.

PARENT SIGNATURE

DATE