FAIRFIELD CHRISTIAN ACADEMY
MEDICATION ADMINISTRATION AUTHORIZATION FORM
SCHOOL YEAR ______ - ______
Student Name ______________________________________________ Home Phone_________________
Grade ______ Address __________________________________________________________________
Physician’s name _________________________________ Physician’s office phone _________________
Name of drug __________________________________________________________________________
Dosage ______________________________________ Time to be given at school ___________________
Drug is to be given 1.) by mouth _______ 2.) by inhaler _______ 3.) other _______________________
Start date ______________________________ Discontinue after ________________________________
Physician’s signature ____________________________________________________________________
(Not needed if a prescription is less than one month old or for over-the-counter drugs)
I request and give my permission to school personnel to assist in the administration for this school year only on
the listed medication to the student named above. I understand that the administration of this medication will not start
until this form has been signed by the parent and the school nurse. I understand that the medication brought to school
must be in the container in which it was dispensed by a physician or pharmacist. Over-the-counter drugs must be in
the original container. I understand that adrenaline injections may only be administered by a registered nurse or by
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 or indirectly resulting from the performance or failure of performance of the assistance requested.
Signature of Parent/Guardian _____________________________________________ Date _____________
Signature of School Nurse _________________________________________
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
FAIRFIELD CHRISTIAN ACADEMY
MEDICATION ADMINISTRATION AUTHORIZATION FORM
SCHOOL YEAR ______ - ______
Student Name ______________________________________________ Home Phone_________________
Grade ______ Address __________________________________________________________________
Physician’s name _________________________________ Physician’s office phone _________________
Name of drug __________________________________________________________________________
Dosage ______________________________________ Time to be given at school ___________________
Drug is to be given 1.) by mouth _______ 2.) by inhaler _______ 3.) other _______________________
Start date ______________________________ Discontinue after ________________________________
Physician’s signature ____________________________________________________________________
(Not needed if a prescription is less than one month old or for over-the-counter drugs)
I request and give my permission to school personnel to assist in the administration for this school year only on
the listed medication to the student named above. I understand that the administration of this medication will not start
until this form has been signed by the parent and the school nurse. I understand that the medication brought to school
must be in the container in which it was dispensed by a physician or pharmacist. Over-the-counter drugs must be in
the original container. I understand that adrenaline injections may only be administered by a registered nurse or by
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 or indirectly resulting from the performance or failure of performance of the assistance requested.
Signature of Parent/Guardian _____________________________________________ Date _____________
Signature of School Nurse _________________________________________
M/Academy/Health/Medicine administration form
