MEDICATION AUTHORIZATION
F
O
R
M
For ALL prescription or over the counter medications administered at s
chool
HEALTH CARE PROVIDER complete this section (MD, DO, ND, DMD, PA, or ARNP) (Please Print)
Medication:
Name/Dose/Time/Route
Is student Capable of
Self-carry & Safe
Administration?
No - Student may not self-carry or administer
Yes - Student may self-carry/administer
Student has been trained in: Purpose, method, frequency, and safe carry of this medication
THIS School Year (includes Summer)
Signature: Licensed Health Care Provider
PARENT/GUARDIAN complete this section
Administered by Staff
ALL Grades: I request authorized school staff to assist my student in taking the medication described above.
Self-Carried and Administered by Student
ALL Grades:
I request my student Self-Carry and Self-Administer Asthma/Anaphylaxis medication.
(Requires School Nurse approval: Approval Granted by:_____________________________________)
Only Grades 6-12: I request my student Self-Carry and Self-Administer this medication.
Student carries only 1-day supply. EXCLUDES: Controlled Substances
(Requires school nurse approval: Approval Granted by:_____________________________________)
I will provide medication in the original labeled container.
I understand that the School Nurse may contact the prescriber regarding questions related to this medication.
I understand the responsibility of self-carrying medication at school; school staff will not be able to track compliance.
As the parent/guardian/or other person in legal control of the above student I agree to hold harmless and indemnify the school
and Auburn School District’s officers, employees, and agents against all claims, judgements, or liabilities arising out of self-
administration and self-carrying of medication by student.
I understand the student, if approved to carry medication, will carry the one-day supply in the original labeled container.
Signature: Parent/Guardian/Student
ASD Medication Policy: 3416, 3419
HS860 (1/19)
