FAIRFIELD CHRISTIAN ACADEMY
MEDICATION ADMINISTRATION AUTHORIZATION FORM
SCHOOL YEAR 20______ TO 20 _______
To be completed by parent or guardian:
• I request and give my permission to school personnel to assist in the administration of
the listed medication to the student named below.
• I understand that the prescription medication brought to school must be in the
container in which it was dispensed by a physician or pharmacist. Over-the-counter
medication must be in the original container.
• I understand that epinephrine injections (EpiPen, Auvi Q) may only be administered by a
registered nurse or someone trained to administer the drug.
• I release Fairfield Christian Academy, its school board, its officials and employees
including the school nurse and the appointed drug administrator from all liability for
damages and injury directly resulting from the performance or failure of performance of
the assistance required.
Student name: ___________________________________________ Grade: _____________
Address: ________________________________________ Phone: _____________________
Signature of parent/guardian: _______________________________ Date: ______________
OVER-THE-COUNTER MEDICATION:
Name of medication ________________________________Dose:______________________
Time to be given: _______________Start date: ______________ End date: ____________
PRESCRIPTION MEDICATIONS:
TO BE COMPLETED BY PHYSICIAN/PRESCRIBER:
Name of student _________________________________ Diagnosis:__________________
Name of Medication __________________________________________________________
Prescribed dosage and means of administration: ___________________________________
Time to be given: ______________ Start date: ______________ End date: ____________
Possible side effects/adverse reactions: __________________________________________
Special Instructions: ________________________________________________________
Physician/Prescriber signature: ___________________________ Date: _________________
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