Madison Central School District

7303 Route 20 Madison, New York 13402

Phone: (315)893-1878

Fax (315)893-7111

AUTHORIZATION FOR ADMINISTRATION OF MEDICATION

A. To be completed by the Licensed Health Care Prescriber:

I request that my patient, as listed below, receive the following medication:

Name of Student:  ________________________________ Date of Birth: __________________

Diagnosis: ___________________________________________________________________

Name of Medication: ___________________________________________________________

Prescribed dosage and route of administration: ________________________________________

Frequency and time to be taken during school hours: ___________________________________

Duration of treatment: _________________________________________________________

For PRN medications - list conditions under which medication should be administered: 

__________________________________________________________________________

Name of Licensed Prescriber & Title (please print): ___________________________________

Prescriber's signature: ______________________________  Date: ______________________

Issuing Physicians Office: __________________________  Phone: ______________________

B. To be completed by parent or guardian:

I request that my child ___________________________________ grade _________________

receive the medication as prescribed above by a our licensed health care prescriber.  The medication is to be furnished by me in the properly labeled original container from the pharmacy.  I understand that the school nurse, or other designated person in the case of the absence of the school nurse, will administer the medication.

I also hereby request that my child's teacher or other designated faculty member administer the medication on such school-sponsored activites such as field trips, athletic events, etc. during the ______________ school year.

The above medication is to be administered during the current school year or ountil terminated by written notice.

Signature of Parent/Guardian: ____________________________________________________

Address: ____________________________________________________________________

Phone (home): ________________________  Phone (work): ___________________________

Date: _______________________________