AUTHORIZATION FOR STUDENT MEDICATION

To the Principal of _________________________ School Date___________________

I, the parent/guardian of ______________________, whose birth date is_____________, request that the
following necessary medication be given to my child at school on a daily or on an emergency basis as
needed. I release school personnel from any liability involved with administering this medication
according to the doctor’s instructions below.

_______________________________ ___________________________ ____________

Parent Signature Parent’s Printed Name Date

In accordance with the request of the parent above I request that the following medication be given to
___________________ by school personnel during regular school hours:

Medication to be given Dosage Time Diagnosis

1. ___________________ _______ ______ _______________________
2. ___________________ _______ ______ _______________________
3. ___________________ _______ ______ _______________________

Does this medication require refrigeration? Yes No

Would this medication prevent the child from

participation in any school activities? Yes No

Do you recommend that this medication be kept Yes No

with the student at all times? (Only asthma
inhalers, Epi Pens, and diabetic medications and
supplies can be carried by a student at school)

Does this student need adult supervision to Yes No

self-administer the medication which will be kept
with him at all times? (such as inhalers, Epi Pens
and diabetic medications)

Are there any potential side effects of these medications Yes No

which the school staff should be aware of?

Are there any additional concerns or instructions ________________________________________

regarding these medications?

Note: If a request is being made to give Glucagon to a diabetic student in an emergency low blood sugar
situation, an additional, specific form, the Utah State Administration of Glucagon form, must be signed by
the parent and physician and kept on file at the school.

__________________________ ______________________ _____________

Physician Signature Physician’s Printed Name Date

____________________ _________ ____________________ _____________

Signature of Principal Date Signature of School Nurse Date

Signature of staff members assigned to administer the above medications:

1.___________________________ 2._________________________ Date ____________