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JLCD-E2 - Administration of Medication to Students Authorization Form

JLCD-E2 - Administration of Medication to Students Authorization Form 

To be completed by the child’s Health Care Provider and Parent/Guardian.

Please complete this form to allow the school nurse or designated school staff member to administer the named medication.  All medication must be brought to school by an adult and will be kept in the school nurse’s office. The medication must come in the original container with the student’s name and prescription instructions labeled. This must be renewed annually or updated with changes to prescription. 

School Year: __________  to  __________

Student Information

Student Name: _________________________________________________     D.O.B. __________________

School: ___________________________ Grade:____________ Teacher: ______________________________

List Any Known drug allergies/reactions: ________________________________________________________

Height: ____________________                                        Weight: _______________________ 

Physician - Prescriber Order/Authorization

Provider Name: __________________________________________  Office phone #:_____________________

Office Address:_____________________________________________________________________________

Medication Name: ________________________________________ Reason: _____________________

Dosage/Route: _______________________                                Frequency: ___________________

Begin Medication: _____________________                              Stop Medication: ______________

Potential Side Effects/Contradictions/Reactions: ____________________________________

When will the student be reevaluated? ____________________________________________


Special Instructions:

Does the medication require refrigeration?          Yes              No

Is the medication a controlled substance?           Yes              No


_________________________          __________                               __________________

Physician Signature                             Date                                               Fax #


As a parent/guardian I request the designated school personnel to administer the above medication at school according to district policy.  Information regarding my child’s medication may be shared with appropriate school personnel.  I authorize the school nurse to communicate with the health care provider.


________________________________________________     _________________________

Parent/Guardian Signature                                                         Date

______________________           _______________________    _________________________

Home Phone #                              Cell #                                           Work #



Adopted: February 28, 2018

Policy Revised: August 18, 2021